Strangest Chief Complaint

"The people I live with said I need new jeans."

Jeans? Silly me, I thought this was a hospital.

contrasting patients

Ambulance patient - sprained ankle 4 days ago
Patient walking into triage -Asian man who is covered in hives and has a blood pressure of 72/30.

I wish EMTALA and the fear of being sued would go away so that the ambulance crew could say "This isn't an emergency." Or we could tell the patients with colds, chronic back pain and the like to BEAT IT! But then I probably wouldn't have a job would I?

Always get their clothes off!

Patient brought in for ALOC. I'm helping a colleague triage the patient. She has been given Narcan in the field and is now awake but had been reported to be obtunded prior to that. I'm writing and the other nurse is hooking up the patient on the monitor. She asks the patient to remove her shirt but the patient doesn't want to. She attempts to reason with the patient, explaining why we want to get her undressed. The patient isn't buying it. This goes back and forth but is going nowhere. I go over to help. The patient asks, for the umpteenth time, why she has to get undressed. By now I'm out of patience and I tell her "because we said so." And the other nurse and I remove the shirt only to find that the patient has on eight Fentanyl patches! The usual dose is one patch applied every three days so she had applied all eight in an attempt to get high and didn't want us to discover them. We removed all eight and threw them away.

Tubes and Orifices

One of the first blogs I started reading was Fingers and Tubes in Every Orifice. Putting tubes in various orifices is a big part of the nurse job. While it doesn't sound very nice, the human body makes a lot of fluids and emanations and it is good to keep them contained.

One day I was getting ready to put a foley catheter my patient and I was explaining the procedure to him. When I got to the part of the explanation about putting the tube in his penis he said "good luck.''

I was startled and rather taken aback, not quite sure what he was talking about but went ahead and pulled back the sheet to reveal a penis that was not only small but had actually retracted into he fat pad over his pubic area.

"oh'' I said, with a straight face, "I see what you mean." well with a lot of lidocaine jelly, some pushing and a lot of luck we got the tube in where it went.

Sometimes it helps defuse the tension to crack a joke or two, but somehow I didn't think this was one of those times.

Gotta learn it the hard way Part 2.

Same doctor as the post below, different day.

Ambulance brings in a patient in four point handcuffs who is agitated and combative. The ambulance crew is accompanied by 2 town police, two sheriff officers and 4 state patrol officers. This is pretty unusual in our sleepy little ER, we are more accustomed to drunk college kids and the like. The patient is a skin-head, covered with prison tattoo's (keep in mind this was before the days when every Tom, Dick and Harry had a tattoo) and he is built like a body builder, with a neck and biceps bigger than my thigh.

He is sitting up on the ambulance gurney, straining against the handcuffs with his neck and forehead veins bulging. He is screaming threats and profanities as the officers, telling them in great detail how he is going to go to their homes and rape, torture and murder their wives and children. The officers seem bored. Personally, I was a little put off. I'm not bothered by most peoples rotten behavior but this guy scared me. If I was the officers I think I might have indulged in a little 'baton therapy.'

After we had moved him and cuffed him to the ER gurney (quite an endeavor, it took all the cops to get him secured. I did not participate!) I asked the ER doc to come in and evaluate the patient. This was several months after the incident posted previously and nurse/doctor relationships had become very strained.

The doc came in, saw the patient and said "start an IV and draw some blood." and walked out. I followed him out and told him in no uncertain terms that I was not going to be doing that until the patient was medicated and under control and if he wanted an IV and a blood draw then he could go in and do it himself. So, intending to show me, he grabbed the IV tray and headed into the room.

As soon as he walked through the door, the patient reared up on the bed so hard that he actally lifted the wheels at the head off the floor several inches causing the stretcher to land back on the floor with a big thump. The whole time the guy had been there he had been threatening everyone with all sorts of vile and evil things. His bulging eyes landed on the doctor and he screamed (heavily edited for profanity) "Come on....bring your little yellow ass over here.....I'm going to tear your little slanty eyed head off and shove it up your little chink ass" The doctor did an abrupt 180 and practically ran out of the room. Without another word to any of the staff he went to the chart and wrote an order for a B52 (a well known shot containing 10mg of Haldol, a potent antipsycotic - 50mg of Benadry, which is pretty sedating and helps prevent side-effects from the Haldol - and 2mg of Ativan, a sedative like Valium.) Although he wrote for 4 mg of Ativan which makes it a B54, but that doesn't flow as well off the tongue.

After the nurses stopped laughing (rude I know, but we couldn't help it)we medicated the patient. Soon his endless flow of vile invective started to slow and not long after that he was sleeping like a baby.

This doctor never grasped the idea that the ER was a place for teamwork and everyone there, including the clerks and techs were an important member of the team and deserved respect. It wasn't long before the head of the Doctor's group got rid of him. I hope he loosened up eventually.

Gotta learn it the hard way part 1.

One of the things I enjoy the most about working in the ER is the close relationship we usually have with our doctors. We work very closely as a team and they know and trust us and that gives us a lot of freedom to do things that floor nurses would never dream of doing.

Every so often though, you get a new doc who doesn't get along with the staff. Many years ago I worked in a rural ED with a small group of doc's that we really loved. They were great to work with, let us order a lot of the labs and xrays to get the work-ups done expediently. Then this guy came along and generally treated the nursing staff like they were nothing more than lowly minions without a brain among them. Needless to say he was not well liked.

One day I was working and he was the doc. We'd already had one major run-in earlier in the day and I wasn't feeling very kindly disposed toward him. The issue was that I had a cancer patient in excruciating pain that he was not treating appropriately with regard to pain relief. After discussing it with him several times then discussing the issue with the charge nurse and the nursing supervisor I had called the patients primary MD who was a great guy. I had explained the situation to this Doc and he gave me admitting orders with generous doses of narcotic. Once the ER doc found out what I had done the evening got a little tense.

My new patient was a big, burly lumberjack looking guy complete with flannel shirt and long beard. He had come in for a hand lac. I had set the doctor up for sutures and left to get some irrigation fluid. When I returned to the room the doc had the patient sitting on the edge of the bed with his injured hand on a mayo stand and was starting to inject the local. I asked him if he wanted me to get the patient laying down to which he replied rather nastily that "he had the patient the way he wanted him."

Well I don't know about anyone else, but I have always found the old saying 'the bigger they are they fall' to be true. And the bigger, manlier guys were usually the ones who would go out cold when the needles started waving around. By this time though, i wasn't feeling very kindly toward the doctor so I just let it go. Before he had injected 1/2cc of the local the patient abrubtly pitched forward onto the mayo stand head butting the doctor in the nose.

Fortunately I had been standing right there and grabbed the patient and laid him down on the stretcher. As soon as he was supine he came to. The doctor, however, wasn't in as good shape, his nose was admirably gushing blood. The nosebleed was treated successfully with pressure and he was able to finish the shift.

I felt bad that the patient had passed out, I sure hadn't been expecting anything that dramatic. I also felt bad that the Dr. had been injured (once I got over the initial inward evil chuckle) even if his arrogant attitude had caused the whole episode. God forbid a mere nurse have an idea about how to treat the patient. The rest of the nursing staff wasn't as kind, they howled with laughter and spent the rest of the night giggling at inopportune moments. The physician remained surly and silent.

Head -1
Doctor's Nose - 0

Just because you can buy it without a prescription

A few years ago I took care of a lady with RUQ abdominal pain. Her history was of increasing pain over the last couple of weeks. She had not sought medical attention earlier because she had not insurance and could not afford to but now the pain had gotten to the place where it was intolerable.
Indeed, she looked pretty uncomfortable. Slightly diaphoretic, holding herself stiffly, hunched over guarding her pain. Noted to be slightly juandiced. Our initial thought was gallbladder disease and our workup followed that path.
Assessment revealed a greatly enlarged and tender liver. Labs showed serious liver failure. It came out that she had a bad tooth that she couldn't afford to get fixed so she had been taking Tylenol by the handful to try and manage the pain.
We ended up flying her emergent to the nearest tertiary center so she could be put on the liver transplant list. Liver failure by unintentional Tylenol overdose. She and her family were devastated.
I've encountered other patients with bad outcomes from not getting the medical attention they needed earlier due to financial constraints. To me, the story of this young woman illustrates why this country needs some sort of program that guarantees adequate medical attention for all our citizens. I expect we'll get there someday but knowing our government and how it runs it will probably be so fubar'd it will be worse than what we have now.

Blue Baby

Triage is the front line of the ER, literally. The triage room is right off the lobby usually behind a locked door that separates the triage nurse from the patients. The triage nurses job is to do an initial intake on the patients and sort them into categories depending on acuity (how seriously ill they are.) The triage categories usually range for 'emergent' (which is otherwise known as 'fixin to die') to 'routine' (which is other wise known as 'what part of emergency don't you get?) A lot of people that come to the ER don't quite understand the part about being seen by acuity. We live in a society with a Burger King mentality. People want it fast and they want it their way, otherwise known as 'instant gratification.'
People hate to wait. I can respect that, I do too. But come on people, do you really think your sprained ankle is more important than the gentleman who's heart just stopped? I honest to God had a woman whip open the curtain to demand the doctors attention, never mind that we were in the middle of a code there....sheesh.
People that have to wait get....shall we say cranky? Add to that mental illness, drugs, alcohol, gang members etc. and sometimes the waiting room can feel more like a war zone. When I worked at county it was nothing for people to wait an hour or two to see the triage nurse not to mention the long, long wait to get a bed in the back. The triage nurse, being the first person the patient see's has to endure a shift full of angry people verbally abusing and harrassing the person they see as a barrier to a room in the back.
All that was a little background as to why I hate to triage. Not to mention the fact that you feel totally cut off and abandoned from the rest of the ER.
One day I was the triage nurse. It had been an incredibly busy shift and I had been triaging non-stop for four hours without a break. The patients had an average wait of five to six hours and they weren't happy. Everytime I opened the door they would come at me in a wave expressing their displeasure in many ways. The security office was right across from the triage room for a reason. I had about had it. I was in the middle of triaging a little old lady who was telling me her whole life story and trying to chart her whole long list of 17 meds. I was feeling incredibly stressed mentally reviewing the ten or so triage cards that were waiting. I was getting real close to bawling out of stress and frustration, and I never cry (except at Disney movies, but that is another story) just about that time someone started banging on the triage door. That was it, the straw that broke the camel's back. I leaped up, grabbed the doorknob and yanked the door open, intending to let whoever dared be on the other side have it good. The door swung open to reveal a very tiny, elderly hispanic lady holding a blanket wrapped bundle that she thrust into my unprepared hands. When a family member shoves their precious infant at a stranger, it is not a good sign. I glanced down at a blue and mottled infant. A moment of "oh SHIT!!!!" I turned and ran out the back triage door, yelling "I need some help in trauma one. I put the baby down and grabbed the ambu bag and hooked it to the oxygen, by that time the ER staff were arriving. I told them what had happened as they swung into action. The ER social worker went to gather up the family. A little bagging with 100% oxygen and the baby started to pink up, the monitor showed an initial saturation of 60% and a heart rate of 40, compressions were done briefly but the heart rate responded to oxygenation. The whole thing took less than ten minutes and the infant was showing vastly improved VS and appearance.
I went back to triage, heart still pounding and hands shaking from the adrenaline. The little old lady was sitting right where I left her "where have you been, I've been waiting here forever." At that point I could only burst out laughing. After that day, triage never bothered me as much, it was only one day every now and then. I can't change how other people act but I can change how I react.
But I definitely will never be able to control how I react when handed a blue baby.

Wheelchair to the parking lot

Page overhead heard....."Wheelchair to the parking lot"
"I'll go" I offer, subconciously rolling my eyes and hoping that it won't be a patient with back pain who miraculously was able to walk to the car at home, drive themselves to the ER and then on arrival became paralyzed. "I'll come with you" another nurse offers and we grab gloves and a wheelchair and head out the door to the parking lot.
There is a small, two-door vehicle in the ambulance bay with the engine running and the doors open, a hysterical woman directs us to the passenger side where we see a large woman who obviously isn't breathing or, from the color of her skin, having much cardiac activity. No time for niceties here, we pull her out onto the wheelchair and rush her into the ER, one of us holding her into the chair and the other one holding her airway open in case she is not breathing because it is closed due to the position of her head.
"We need some help in here" Magic words that mobilize the troops. Up onto the stretcher and slap on the quick combo pads, another nurse is starting and IV, another nurse and the doctor are getting ready to intubate. "what happened here" the doctor asks. The woman who was driving thinks the patient may have overdosed, she went to visit and found the patient acting strangely so she coerced her into coming to the hospital. On the way the patient became less and less responsive. The poor woman driving was terrified but being a short distance away managed to get her here quickly.
Monitor shows v-fib. The patient is defibrillated three times without response. CPR is started, the patient is intubated and oxygen is pumped into her lungs. Once an IV is established meds are given. A few minutes of CPR to circulate the meds the she is defibrillated again with results -a return to a perfusing rhythm! More interventions follow but soon she has stable VS and is making some movements of her extremities. Whisked away to the ICU only time will tell how she will do, since she probably arrested within minutes of the hospital maybe she will do OK.
Ah, the ER. Most of our patients are routine, Abdominal pain, nausea and vomiting, back pain, chest pain, shortness of breath. But interspersed with that are moments like these that fill you with pulse pounding adrenalin. I love it!

Breast cancer

she was brought in by her family, they had wanted to bring her in months earlier but she wouldn't cooperate, now she was so weak and short of breath she couldn't fight anymore. We took her back and undressed her, there was a horrible smell...like that of a mouse nest full of dead and decomposing mice. She fought against us removing her shirt and bra, we gently persisted. When the last layer was removed we had found the source of the smell, her entire breast was necrotic, blackened and draining purulent material. Breast cancer left untreated so long it had eaten thru the skin. We gently tucked her in with warm blankets, lots of oxygen and morphine. Appalled we spoke to the family, they were terribly distressed. Had suspected that something was wrong but the patient was so private and proper she refused to discuss it. Indeed, even though her oxygen saturations we in the low 70's when she arrived, was impeccably dressed down to nylons and jewelry. The doctor spoke to the patient and family, there was no option of treatment, a chest xray told the terrible tale - multiple lesions throught the chest. Her denial broken the patient died within hours, surrounded by her bewildered, grieving family.

Another Day in Paradise or Blood Alcohol Pool

Drunks are a big part of our clientele. Unfortunately, people that have been drinking hard for a long time are not nice people, they are mean....belligerant and looking for a good fight. People that drink enough to be brought to the ER are often homeless and hygenically challenged.
The usual scenario is something like this:
Concerned citizen is driving along and notices someone facedown on the sidewalk or in the park. Fearing the worst (dead) they call 911 on their cell phone. Police and EMS arrive to find a drunk laying in a puddle of vomit and urine. Now I love the police, ER personnell and the police have a close relationship, but obviously the police don't want them so if the drunk can be woken up they'll give them a choice of hospital or jail. Guess which one usually gets chosen. So the ambulance brings the patient to us, agitated, spitting, smelling to high heaven of God knows what. So what follows is usually something like this.....Big wrestling match with several nurses, security and often the police to get the patient in four-point restraints and a spit mask so when he spits it just goes back on him. Get the clothes off and into biohazard bags, debate whether to take the shoes off (homeless people wear the same shoes and socks 24/7 for months on end until the food odor is so noxious that it can permeate the entire ER and make the regular patients gag) decide to leave them on for safety sake. Insert an IV and draw blood for the medical clearance exam and a catheter so all the urine will be safely drained into a bag instead of dripping off the stretcher onto the floor. Raise the head of the bed so if they vomit they won't choke to death and apply all the usual monitors to watch vital signs and oxygenation. A couple warm blankets and a sitter and they are left to sleep it off while we wait for lab results.
What follows is known to most ER people as "the Blood alcohol pool" one dollar per person, closest guess without going over wins. Most drunks that are brought to the ER have BAC readings well into the .3 or .4 range, a place that would be deadly to most of us. Just a little bit of levity to lighten our day.
On the flip side, these patients clog our ER's and cost taxpayers and hospitals billions of dollars a year. There is a revolving door of visits in our community.....To the hospital, cleared medically and to jail, released from jail a few hours later and to the local liquor store and back to the hospital all with in the same day sometimes if the drunk is intrepid and gets an early start. God forbid we step on somebodies right to the pursuit of happiness but it seems to me that since they are costing society and not producing anything in return it might be cheaper to just lock them up somewhere and keep them there freeing up police, EMS and hospitals for something a little more important.

Bringing back the dead

Many years ago (14 actually) when I was a fairly new ER nurse I worked in a little tiny hospital on the Saint Lawrence Seaway in far upstate NY. We were so far north that we could see Canada across the river! Our ER had four beds and was staffed by a PA. In the summer during tourist season it could be quite a hopping place but in the winter it was just me and the PA. It was January and it was well below zero outside. There was one patient in the department that we were ruling out for an MI. The first set of enzymes were negative and the patient was pain free and asking for lunch.
The PA left to go down and get his own lunch, I was talking to my patient when she said those words that strike fear into every nurses heart....."you know dear, I really don't feel very well." I asked if she was having chest pain, which she denied so I tried to get some more specific information. While I was asking questions her eyes suddenly rolled back in her head and she went out, I glanced at the monitor and saw vtach. To be honest, I almost wet my pant, I was still very new and very wet behind the ears and there I was in the ER alone with a woman who was very quickly heading toward the light. I don't know how long I stood there, it felt like an eternity but it was literally seconds before I snapped to it.
We had a switch on the nurses desk that was basically a silver toggle switch. I toggled it and the code bell started to ring throughout the hospital. From there I ran and got the crash cart. No fancy biphasic lifepack there, just an old Hewlett-Packard defibrillator without pacing capabilities, the pacer was a separate item. I whipped out the paddles, charged up the defibrillator and put them on her chest. At the last minute I remembered the gel, squirted some on and defibrillated her one time. When the tracing returned to the baseline I could see some complexes and checked her pulse, praise the lord - she had one! At that moment the PA arrived and some of the floor nurses upstairs but there wasn't much to do, the patient was concious and to my astonishment still answering the last question I had asked her. My legs were shaking so much I suddenly needed to sit down.
When all was settled the patient was on a lidocaine drip and in the back of an ambulance on her way to Syracuse to have a heart cath after which she had open heart but did very well. She had no recollection of the event, didn't even "see the light" but she did say that she had felt like "being kicked in the chest."
ACLS, Defibrillation and cardiac care has come a long, long way since then. Ive seen a lot of people saved even though it is not like on TV and we don't save them all but it is one of the things that make me love the ER. Sometimes ER nurses get the chance to make a BIG DIFFERENCE!

Why an ER nurse

I graduated from nursing school in 1990, I was 31 at the time and had a family. when I look back at those school years I have to wonder how the hell I survived. I worked full-time evenings, eight hours a day, five days a week. School was 45 miles away. I lived in Upstate NY and the winters were.....challenging. I remember driving home on day and my car died, I knew I wasn't out of gas as I had just filled up the tank. I called AAA and explained the situation and they said "sounds like your gas froze." Froze!? WTF? I didn't know gas could freeze. So for three years I existed on about 3 or 4 hours of sleep a night. Maybe that's it....I just don't remember any of it, it all happened in a lack of sleep fog!

Anyway....my first job was on a med-surg floor. I got about 5minutes of orientation and then I was in charge and the only RN on the floor. Pretty scary, thank God for the wonderful LPN's and Nurses Aides I worked with, they taught me a lot and kept me from killing anyone.

About 1 month of that and I was bored senseless. I set my sights on the ER and except for a couple of forays into the ICU, have been there ever since.

ER nurses are a special breed, we deal with a lot and so we are tough, tenacious and assertive. Some read that as bitchy but it isn't true. A day in the ER can range from the incredibly boring to the truly terrifying and it can change in an instant. We have no control over the type or number of patients that come through our doors. Our patients and their family members are under a great deal of stress and that sometimes causes them to act unpredictably. ER nurses suffer more assaults and related injuries than any other group of nurses. We also suffer a higher rate of burnout than any other specialty. It's not for everyone but for some it is the only thing.