A little venting of the spleen

There is a really funny post over at M.D.O.D. Check it out

I am going to indulge in a small rant about co-workers, this is not an interesting ER story so feel free to skip it, but I need to vent.

To the people I work with....YOUR MOTHER DOESN'T WORK HERE. At least once a day I go into the lounge and throw away myriad used napkins, half-full cups of beverages, plates with food residue and all sorts of trash. Are you not grown-ups? Do you leave this shit all over your house? And the doc's eat and leave their food trays on our table. I have taken to putting them on the desk in their lounge which is attached to our breakroom, I think they are getting the message.

Why is it that when some people prepare meds they leave the empty vials, unit dose packages, packaging from mini-bags and tubing all over the counter. Now mind you, the med room is 5 foot square and there is a garbage can touching your left calf as you a preparing your meds, apparently it is too difficult to turn your upper body 90 and drop the trash into the can.

It's hard to be taken as professionals when we can't even clean up after ourselves.

Sick Kid

Triage nurse brings a kid into my room saying she is concerned because the kid's respiratory rate is seventy. A quick look into the room shows a child about three, laying listlessly in moms arms, and is definitely panting. Here is a secret - except for a select few who choose to work in peds ER's, most of us are scared to take care of sick kids. It's not that we don't know what we are doing, it is just horrific thought of what it will be like if the kid doesn't get better. And while adults will have a slow decline, kids can compensate for a long time and then collapse. This kid was there, the compensatory mechanisms were all used up.

I quickly enter the room and introduce myself to mom. The kid looks like a respiratory problem, so remembering the ABC's and PALS I place her on high-flow oxygen. I put her on the monitor and, thinking that I am dealing with a respiratory problem, put the oximeter on first. As soon as it is on I can see the pulse is abnormally high, way over 200. I stick my head out the door and say the magic words "I need some help in here."

One nurse grabs the doc, one grabs the pediatric crash cart another IV stuff. I finish putting the monitor leads on which show the kid is in SVT with a heart rate of 330! Two nurses are trying for IV's which are unsuccessful. In PALS we learn to go for intraosseous access if two IV starts are unsuccessful but in reality, nurses aren't allowed to do this and most of our docs have never done one and are very reluctant to do so, this doc being no different. We put the pedi defib pads on the kid but are reluctant to cardiovert an awake child with no IV access.

The usual treatment for this arrhythmia is immediate cardioversion if the patient is unstable, which this kid is. We deliver a synchronized shock to the chest which is supposed to briefly stop the heart allowing the normal conduction system to take over. Rarely, when you do this, you will cause the heart to fibrillate - necessitating a different kind of shock, called defibrillation, and IV ACLS drugs. If the patient is stable you can try vagal maneuvers to stimulate the vagus nerve which slows the heart rate. If that doesn't work, there is another treatment - an IV drug called Adenocard, which chemically stops the heart briefly like cardioversion.

This all happened within a couple of minutes but it seemed like hours. The Doctor asked us to get a bag of ice. Someone ran to get it. When it was brought back he took it and held it over the childs face for a few seconds. Surprised, we watched in amazement as the heartrate converted to sinus tach at around 120. Almost immediately the kid started looking better. With better perfusion we were able to obtain IV access and do some fluid resuscitation. A transfer was arranged to the tertiary care center for cardiology consult. By the time we put her in the back of the ambulance she was alert and coloring. Still, we all breathed a collective sigh or relief when the ambulance pulled away.

We asked the doctor how it was that the ice worked to convert the heart rhythm. He explained that it was thought that the sudden cold activated the mammalian diving reflex which slowed the heart. He wasn't sure if that was it or the few seconds of trying to get a breath stimulated the vagus nerve but he had seen it work on a kid when he was a resident and decided to give it a try.

Change of shift time

It's Change of Shift time over at Protect the Airway. That is one of my favorite blogs with Rules of the ED Parts 1, 2 and 3. They are hilarious, check it out. One of my favorites is:

"28. Please don’t bring in a show and tell. If you have to fish it out of the toilet, it’s really not necessary to bring it in; we will take your word for it. If you did fish something out of the toilet, you may not use my pen"

As a general rule I don't let patients use my pen anyway, as a consequence of my profession I have become slightly germ-phobic. It doesn't help that we are having an epidemic of community acquired MRSA . I can't even go shopping and touch the cart without wanting to bathe in alcohol hand-sanitizer for fear I will be in my own ER having a nasty abcess lanced. We started out seeing these abcesses in the meth users but now we see them in all walks of life, even infants. Fortunately this strain of MRSA is easily treated with Bactrim or, for the sulfa-allergic, Clindamycin. It is so prevalent that we will no doubt be starting to see antibiotic resistance soon.

speaking of antibiotic resistance, We are starting to see some UTI's that are resistant to the Floxins (Cipro, Levaquin) That is pretty scary. Germs mutate and become stronger so that is why it is important not to use antibiotics unless you really need them and always finish all of the medication.

One wild night

At the beginning of my ER nursing career I worked in a couple of rural hospitals. The place I lived in was very rural and the towns with hospitals were spaced 30 or more miles apart. There was no such thing as diversion, you just dealt with what you got. Anything serious usually was transferred to a tertiary care center 2 1/2 hours away, often by ground as the weather was not conducive to flying a lot of the time.

It was the 3 - 11 shift in our ten-bed ER. We were staffed with three RN's. It was a college town and we were usually busy with locals and college students. The ER was packed that night. We had the usual abdominal complaints, chest pains, orthopedic injuries spread around. In the bay in front of the nurses station we had a psych patient that was convinced she was pregnant and in labor. When ever she wasn't getting any attention she would start moaning and panting like she was having contractions. Never a dull moment.

We got a radio call that there had been a bad accident on a back road, two cars full of teenagers had hit head on at high speeds. Two were dead at the scene and they were bringing us the other 5. Five traumas in an ER staffed with one doc and three nurses! Yikes! Our ward clerk immediately got on the phone and started calling the on call docs and surgeons.

It was bad, all five had serious injuries. Two of them obviously had bad head injuries. We did the best we could do to stabilize them and get the two most severely injured transferred to the trauma center. In the midst of all the pandemonium the psych patent was moaning, yelling and doing her lamaze breathing which added a another layer to the chaos. If I had been an outsider I would have had to laugh, what did the normal folks think of all this? Only in the ER.

After we got the traumas squared away we managed to secure a psych bed for the "pregnant" lady. By then the shift was over. No breaks, no dinner, not even time to pee. Ah....the life of an ER nurse.

Prehospital Providers

I'd like to say a word about prehospital providers:
We LOVE you.
From the fire department first responders all the way up through the levels of EMT to Paramedic - you guys do an extremely difficult job under the worst of circumstances. You respond to scenes never knowing what the situation might be (here is a post on
March of the Platypi on some bizarre scenes) you go into people's homes which are often awful, you deal with the gamut - mansion to homeless camp. You comfort and stabilize the patients and always greet the ER staff with a smile and a joke. I've been on ride alongs and have enormous respect for the jobs you do so well. Thank you.

"I've never had sex"

Thirteen-year old, morbidly obese girl comes in with her mom with a chief complaint of abdominal pain. When taking her history she denies sexual activity and has not yet started her period. We draw and send off some basic labs, given the girls history of not starting her menses, the PA doesn't order a pregnancy test. The labs and urine come back non-diagnostic. Meanwhile the girls pain seems to be intensifying,coming in waves. One of the more experienced nurses tell's the PA she thinks the girl is in labor. He poo-poo's the idea, "she's never had a period and isn't sexually active." Now we all know that our patients always tell the truth, right? The nurse prods and prods and finally the PA decides to do a pelvic. (small rural ER, no ultrasound in department and ultrasound tech on call as it was weekend.) Patient undressed and noted to have some vaginal bleeding. Now the PA has decided that all her pain is coming from starting her period. By now the patient is really writhing in pain. An argument ensues between the nurse and the PA (at the nurses station) but finally he goes back into the room to do a pelvic. Legs into stirrups and.....now it is obvious that she has a bulging perineum and a quarter sized area of hair that isn't hers! OH CRAP! Much rushing around by all the staff and viola - delivery of a healthy 5 pound infant. Mother and baby did fine. The new grandmother was quite stunned. The ER nurses had to have a drink after work and the PA gained new respect for the experienced nurse.
But seriously, this episode went well. The mother had had no prenatal care obviously, and that can lead to disaster. ER nurses don't like obstetrics, we'd much rather deal with trauma. Wet, slimy newborns are scary! Nurses that work in ER's where they don't deal with a lot of peds are very stressed by having to take care of a neonate! Not all ER's have the luxury of being in a hospital with obstetrics where you can wisk a pregnant woman off to. And thanks to EMTALA, if they are past a certain point in their labor, you can't transfer them (righly so, back in the old days unstable women in labor were transferred inappropriately with some bad outcomes for mother and infant.)
I have nothing but respect for OB nurses, give me dueling cardiac arrests any day over a delivery!

Why are we ignoring the mentally ill?

The nation's mental health services, what is left of them, are a disaster. People who need services have nowhere to go because all the beds have been defunded. The mentally ill are a people we prefer to keep invisible which makes it very easy for politicians to cut funding for those services.

The mentally ill become homeless, they fill our prisons and ER's. Wouldn't it be better to provide them with the services they need?

For a thought provoking post on this issue, check this out.

Nursing Ratio's

This is the most beautiful idea I have ever read, thanks N=1

'Indeed, hospitals will be so much better served when professional nurses and contracted physicians evaluate the administrators and managers, and thus control the salaries and career paths of them. By placing patients on top of the pyramid, with clinical nurses and physicians and therapists directly underneath, with support services (such as hotel, dietary, environmental, biomedical engineering, IT, medical records, etc) supporting the clinicians, and at the very bottom - supporting the whole organization, the administrative team, hospitals will finally get it right.'

I have a dream. My dream is that nurses will realize their power, band together, rise up, quit their jobs and become groups of independent practitioners instead of petty backstabbing and bickering. In that dream those groups will tell the hospital how they will practice and what tools they will need to achieve that. Patients will be well cared for by nurses who have the time to provide that care instead of doing time wasting reams of government mandated paperwork. The nurse professionals will be responsible for their own practice, much like physicians, using well established practice guidelines and peer review.

Nurses care about patients.

Hospital administration care about profits.

Period.

The Emperor isn't wearing any clothes! Hasn't anyone noticed?

Picture this, you are running a business. There exists a governmental regulatory agency who's purported purpose is to make the people your business cares for safer. Their way of accomplishing this is to drop in every other year or so and inspect all your paperwork, policies and procedures and facilities. Then they hand down this years rules and changes which you must adopt and folow, they are completely different mandates than the last time they were there so that you are never completely in compliance with their rules, after all - they have to make sure of their continued existance. Now matter how ridiculous their rules and mandates are, you don't dare say anything because they have the power to take away your biggest source of reimbursement.

Sounds hard to believe, doesn't it. Why would a business put up with this ridiculousness? Well hospitals do everyday, it is called JCAHO.

To the layperson, having a regulatory agency to oversee hospital operations and ensure patient safety sounds like a good thing, right. Well in theory it is, otherwise greedy hospital administrators would have the sole concern of making gobs of money and give a hoot about the patients. But......

JCAHO comes to the hospital, makes a brief tour and questions one or two person on each unit to make sure they can spit out the rote list of rules that we are supposed to be following for the current year. They may briefly talk to a patient but more likely not. They do spend a lot of time looking at a few charts and policies and procedures.

What they don't do is contact present and past patients to find out if there were enough nurses to care for them properly, if there was enough staff to answer their call bell in a timely manner. If their nurse had time to really teach them about their meds when she was passing them out or if she was so overloaded that she basically watched the patient swallow them and rushed on to their next task.

What JCAHO mandates have accomplished: A nurse now has to spend approximately 1/3 to 1/2 of their shift doing JCAHO mandated paperwork, most of it repetitive. In a twelve-hour shift that adds up to 4 to 6 hours not spent at the bedside where the nurse can do the most good. They have also ensured that the hospital has to have a huge contingent of people who's entire job is to generate new forms and policies, instead of hiring more nursing and ancillary staff to care for the patients. This burden of paperwork has caused a lot of RN's to leave bedside nursing in a time when there is a critical nursing shortage.

With all these rules and regulations and paperwork to fill out to show that you have followed the rules and regulations are things any safer for hospital patients? NO. RN time at the bedside has been repeatedly shown to improve patient outcomes. Filling out reams of paperwork takes the RN away from the bedside. Overworked, overstressed RN's have to hurry to finish all their work and when you are rushing, mistakes can be made. Just because nurses fill out all of the required paperwork does not mean that patients are getting any kind of adequate care.

It is time for us to stand up and say "this is ridiculous, JCAHO (along with EMTALA)needs to be reformed" what has started out as a good idea has turned into a ridiculous example of Government waste who's entire focus is to continue their own existence. All the Hospitals in the country need to stand together on this. More and more paperwork does not ensure better patient care, in fact it accomplishes the opposite. It needs to stop.

I'm not saying that hospitals don't need oversight, they do or otherwise greedy hospital administrators will cut everything to the bone to increase their profits. But the oversight agencies need to look at what really ensures patient safety. Adequate staff to care for them, adequate time to teach them what they need to know, adequate tools and supplies for the staff to do their jobs.

Bright Spots of the Day

I triaged an elderly gentleman who came into my triage room and gave me a Dove chocolate heart to "thank you for all you do."

The ER docs gave all the nurses a rose and a Starbucks card

Our director bought us enough candy to sink the Titanic as well as giving us acknowledgement for all our hard work. Our director supports the nursing staff and is constantly fighting to get us more staff, supplies and resources. What a blessing.

One of the Internal medicine Docs brought in a box of chocolates himself instead of sending it over with his office staff because he loves us.

The sun came out after several days of rain and it is 65 degrees in February!

Happy Valentine's day everybody.

Rules

There are a few rules that should be self-evident but since we see many victims who didn't follow the rules I'm going to list them:
1. Gravity always wins. A high blood alcohol will not change that.
2. Driving 80 MPH in a snowstorm is stupid.
3. Hitting the back of a snowplow while driving 80 MPH in a snowstorm is nearly fatal.
4. Seatbelts are not big brothers way of controlling your life. 99.9% of all fatalities in a motor vehicle crash were not belted.
5. A human that is ejected from a car travelling 80 MPH is still traveling 80 MPH when they hit the ground. A human meeting the ground at 80 MPH will never survive
6. A human that is ejected from a car that then rolls over on top of them also will not survive.
7. If you are going to carefully secure your child in their car seat but not wear your own seat belt you will get points for securing your child but your child will now be known as an orphan.
8. Driving your snowmobile 100MPH at 2 am on a frozen lake is not a good idea, ice heaves.
9 A snowmobile that hits an ice-heave at 100mph will stop suddenly ejecting the human.
10. Human beings that are ejected from a snowmobile traveling 100mph can travel 20 feet through the air before hitting the ground.
11. Drinking for several hours with your buddies and then getting in your car to go to hunting camp with your loaded guns is not a good idea.
12. When said gun discharges buckshot into the drivers ass though the seat, the xray will show no part of the iliac crest larger than a pea.
12a. A shattered iliac crest bleeds. A LOT!
13. A desperate drunk will drink anything. Lock up the alcohol handwash and the listerine.
14. an alcoholic can have a blood alcohol that would be fatal to a normal person and be awake and asking for a sandwich.
15. about 80% of all traumas can be attributed to alcohol and/or drugs.
16. When you fail to heed the above rules and end up in a truama center be aware, a rectal exam is part of the trauma exam and by the time the intern, the attending, the surgical resident and his attending all do their exam you may be feeling rather violated.

Words of wisdom

I don't have anything interesting to say today but I did read a couple of excellent posts that I think are must reads:

The first is from Flea on the need to repeal EMTALA.

The next is from Dr. Tim on why it is important not to pull rank if you want great care in the hospital.

Please take the time to read these great posts and share with your colleagues.

Patient Dumping

I read in the paper today that LA hospitals are under scrutiny for patient dumping. The story said that a medical van drove up to skid row and put a paraplegic man dressed in hospital jammies out on the street where he had to scoot down the road on his butt carrying his clothes in a hospital bag clenched in his teeth. The other skid row residents, fine upstanding people no doubt, yelling "where's his wheelchair?"

Sounds pretty bad right? What kind of hospital would do a thing like that? Let's take a minute and imagine what probably did happen.

Police bring in a drunken, stuporous, homeless guy who was found passed out on the sidewalk. He is so drunk that he has urinated, defecated and vomited on himself. He is taken to the local ER where he has been seen in this condition numerous times. Several nurses take the time to wrestle with the uncooperative and assaultive patient to get him out of his disgusting clothes, cleaned up and in clean jammies. To thank them for their tender care the patient continually tries to punch, kick and spit on them. When he sobers up he is discharged home which is the street, where else are they supposed to take him? The Hilton?

What about his wheelchair? He didn't come in with one, believe me if he did the hospital wouldn't want to keep it, it would be as filthy and disgusting as it's owner. What are they supposed to do, give him a new one because he was too drunk to know where the old one is? Is the hospital supposed to be responsible for everyone who can't be responsible for themselves now?

And as for newspapers, don't get me started, you'll get quite a rant. Let's just say that being allowed to print this skewed, one-sided drivel is criminal and should be treated as such.

Change of shift is up at Nurse Ratched's Place. It's a special Valentine's edition to be enjoyed with a chocolate heart! It's my first time in change of shift and it's very exciting!

Nursing is an Art

Nurses deal everyday with a lot of high-tech equipment. We use electronic charting systems, various monitoring systems, IV pumps, Computerized drug dispensing systems and many other devices. Sometimes we become so caught up in the technology that we forget the basics.

Dry, unwrinkled linens. Soft pillows, Turn off the harsh flourescent lights, making sure the patient is warm enough. Mouth care.

Sometimes in the chaos that is the ER we neglect the small things. But it is the small things that mean the most to the patient.

ER Overcrowding

An incredibly horrible few days, no inpatient beds and half our ER was admitted patients holding for beds. Our state enacted nursing ratio's a few years ago. When this first came up I was excited, feeling that ratio's would be a good thing. Well I guess they were, if you are a floor nurse. The ICU nurse can say they can't take another patient because they already have two. The med-surg nurse can say they can't take another patient because they already have five. The ER nurse is supposed to follow those ratio's also, but in reality ratio's don't work in the ER because you can't stop new patients from coming. If all the ER nurses stuck to the ratio's who would be caring for the sick, injured and dying people who still keep coming? Should we make them sit in the waiting room for hours or days until there is a spot for them? That is not the answer. Going back to the way it was before the ratio's is not the anwer either, when a floor nurse could be expected to care for 10 or 12 patients. But there has to be some middle ground, some flexibility that allows for the patients to get the care they deserve. And the critically ill patient who is laying in the ER sharing his nurse with three or four other patients is not getting the care he needs. The dying woman deserves a quiet room where she can be surrounded by her loving family, not a noisy environment with a screaming, psychotic mental health patient in the adjoining bay. Admitted patients who are being charged for a hospital room deserve to be in a hospital room with a bathroom, TV and phone. Not a curtained cubicle where they have to use a commode with no privacy.
Part of the answer is to get rid of the reams of tedious, repetitive, ridiculous paperwork that JCAHO dictates that nurses do every day so that nurses actually have time to take care of their patients. But that is a post for another day.

I love my job

We had an incredibly bad day, why do Mondays suck so? Ambulances pulling in one after another, people streaming in to be triaged, the lobby was a war zone, frankly we were afraid to go out there, I finally had to station a security guard out there to keep control. In the midst of all the chaos arrived a sweet, petite grandmotherly lady with vague complaints of back pain. Normally she would have gotten triaged to prompt care and waited for several hours to be seen, thankfully today at the very end of triage she mentioned as an "oh by the way" that she had a whooshing feeling in her belly. Today, thankfully, the triage nurse was a well seasoned ER veteran. The sweet little lady, protesting all the way that she would be happy to wait so the other people could get seen, was whisked to our critical care bay where she got a brief exam by the ER MD, whisked to CT scan by her nurse and found to have a dissecting abdominal anuerysm. Rushed back to the room the surgeon was called post-haste and, miraculously, was in the hospital. He arrived at the bedside in under ten minutes. While he was examining her, she said "Oh" and had a seizure. The monitor showed a heart rate of 20 - code blue was called and cpr started. Obviously her anuerysm had burst. We got back a pulse and a very low BP and rushed her to the OR. Two ER nurses stayed in the OR to help the anesthesiologist hang blood and pressors while surgery was begun.
The outcome? She went to the ICU, was extubated the next day and went home 5 days later with no apparent problems. The ER staff received two dozen red roses and a 3 pound box of chocolates from the grateful husband.
So many things could have gone wrong, if the triage nurse was inexperienced, if the patient hadn't said that last sentence she could have coded in the waiting room. All the pieces fell into place that day and we did what we love to do, save a life!

How to Trash a Trauma Room

The 11am shift, twelve hours of running and I loved every minute of it. My assignment today was trauma so I head off to check the trauma room.
The trauma room is one large room with two bays set up in mirror image of each other. Along the side walls are carts with drawers, in the drawers are Dressing materials, NG tubes and equipment, Foley Catheters and insertion kits, IV equipment, IV fluids, Pleuravacs and chest tubes and Medications. Along the bag wall is the blood cooler, and drawers with airway equipment and all the special trays like the open chest tray, the code blue tray and stuff like that. Each drawer, when used, had to be inventoried, restocked and closed with a locking tag that the nurse had to initial. Needless to say, we hated to open the drawers.
When I had trauma I liked to make sure all the suction, oxygen and airway stuff was there and working. The blanket warmer was stocked and there was uncrossmatched blood in the blood fridge. I didn't like to find out some necessary piece of equipment was missing in the middle of an emergency
I get to the door and look in and stop in shock, the room is trashed! The drawers are almost all open and equipment is strewn willy-nilly around the room. The floor is covered with blood linen and other detrius. Soiled 4 x 4's litter the room. Even the open chest tray drawer is open. I have never seen the room look like this and can only envision the trauma that must have occured, perhaps a gang war, or multiple vehicle accident on the Thruway. My curiosity is piqued and I go to find the charge nurse and ask what has gone on. She makes a sound of disgust and tells me that a woman had delivered in her car before arriving at our hospital and they had taken her into the trauma room to deliver the placenta!

Of Kidney Stones and Distended Bladders

There are some things we do on a regular basis that are very rewarding, helping someone who has a kidney stone is one of them.
Kidney stones are excruciatingly painful and when a patient has one it is readily apparent, they present looking pale and sweaty, moaning and vomiting from the pain.
One of the best meds for kidney stones is Toradol, a potent drug in the same family as Motrin (thanks Erica for bringing the error previously here to my attention!), it blocks the spasmodic pain from the ureter contracting against the blockage. We also give a medicine to help with the vomiting and sometimes narcotics.
In a little while the patient is looking calm and comfortable. Very satisfying to be able to help someone so much by doing so little.

Another one is for people, who for what ever reason, are unable to pee. Imagine your bladder as full as it has ever been than double that. Very uncomfortable and painful. We usually greet them by quickly inserting a foley catheter to drain the bladder. Immediate relief. The bladder is meant to hold a cup or two of urine and we often drain a quart or two. OUCH! The patient feels immediately better. Again, very satisfying

All used up

Four long 12-hour shifts and this is all that is left LOL

The Scourge of Meth

He was 12.

Naked, dirty, hog-tied and carried in by the police.

He lay thrashing on the stretcher, screaming, incoherant. Mudcaked limbs and hair. Heart rate was 160 and blood pressure high. Temp 105. The police were called for strange acting person in the woods near a housing division, this is what they found. He probably weighed 100 pounds, it took 4 grown men to subdue him.

It took 8mg of Ativan and 40mg of Haldol to get him under control. Those are massive doses even for an adult. Urine tox showed positive for Methamphetamine.


She was 41. Also naked and shackeled, brought in by police who had found her crouched under the sink in her apartment. Her arms were cuffed behind her and they were walking her down the hall, with each step she raised her leg and tried to bite it. Her teeth were rotten and her skin pocked with sores and scars. She was emaciated. The officer handed us her drivers license, a picture from two years ago showed a beautiful girl with glossy blonde hair. They told us that she had been a successful business woman with her own company before she started using meth.