Strange things found in various places

You can read various ER blogs and find many posts on foreign bodies, especially in the rectum. That is old hat.

In my ER experience I have seen:

A spoon in the stomach. (psych patient that said it was an 'accident')
A toothbrush in the stomach (same patient, same lame story)
A bottle of aspirin, all the pills still in the bottle and the childproof top still intact. (OK, how the hell she does this I'll never know but the gastroenterologist is losing his sense of humor)

Four 1 1/2 inch long screws swallowed accidentally while holding them in the mouth while hanging a picture. (Four? They were pretty long and you couldn't notice them going down?)

Play dough packed into an ear canal. This was rather laborious because you can't grab play dough, it just crumbles. The PA, nurse and ER tech were rather sweaty when they were done wrestling with this kid.

Beads, rocks, beans, peas etc. etc. etc. in ears and noses.

A metal rod up the rectum, perforated the bowel 4 times and came to rest under the diaphragm. I still believe this was a criminal act but the police didn't agree, the patient was psych so maybe.......But you'd think the first time you went thru the bowel you'd stop.

A large hexagonal nut used as a cock ring (to prolong erection) Very bad plan, ring cutter wouldn't work. Penis was black because he had waited so long. Thank God for the maintenance man and his Dremel (bet that company never envisioned their product being used for that!) I don't think the maintenance man ever recovered.

A pen in a mans urethra (what the heck?)

Ball bearings in a bladder. 8 of them to be exact, and they weren't all that small either.

Half a sweet-potato in a vagina (to hold up a sagging uterus) Removing that was more than my sensitive gag-reflex could handle. I've never eaten a sweet potato since that day.

MUST act

California Congresswoman, Mary Bono has introduced important legislation that could be an important first step in mitigating one of the most important factors that lead to ER overcrowding. She proposes changes to the tax-codes that will allow tax write-offs for physicians providing federally mandated, unreimbursed medical care.

I think this is a Damn good idea and intend to support it. Read about it here and write to you local and state government and encourage them to follow suit.

The Academy Award Goes To......

The police in our community are some of the finest people I know. I respect them greatly for the incredibly difficult job that they do. I want them to be on the street protecting me so when they come in with a patient I try to do all that is in my power to expedite the process and get them back to their jobs.

The other day the ER was in mass confusion when an officer showed up at the desk asking for a gurney to be brought out to his car. Usually they bring their patients in, dragging them if necessary, so this was an unusual request. When asked what the problem was he told me he had a guy seizing in the back of his squad car. Apparently he had arrested the guy on a parole violation and couldn't get him to cooperate with the blood draw so they were taking him to the jail where they have a chair that restrains the person enough so that blood can be drawn safely. On the way to the jail, the guy started flopping around in the back seat having a seizure.

"sounds to me he's trying to get out of getting arrested." The officer rolled his eyes and laughed saying, "yeah that's what we thought too." Another nurse and I took a wheelchair out to the patrol car. A twentyish white male was sprawled across the back seat twitching and jerking to beat the band. I've been a nurse for a long time and I know that this isn't a seizure. The officers haul him out and into the wheelchair where the performance continues. Now that he is out of the car and I can see him I recognize him as one of our regular 'back pain' patients. They wheel him in and shackle him to a gurney. When he thinks no one is looking he peers out under his fluttering eyelids.

The other nurse with me, a hardened ER veteran with a lovely Irish accent tells him "you're wasting your time, that isn't any seizure - we're not stupid don't you know." The cops crack up. He continues flopping around but the police phlebotomist is there so we assist in restraining him so the blood can be drawn. Amazingly, as soon as the needle enters his arm he makes a miraculous recovery and starts cussing and spitting at us. The blood is drawn and he gets a cursory medical clearance from the ER doc who is not impressed at having to waste time on this clown. He leaves the ER on his feet, shackled and assisted by two officers.

We get back to our routine but every so often we remember the experience and shake our heads with a chuckle.

Change of Shift Time Again

check it out over at Codeblog, and it is in rhyme! enjoy.

Hey! someone gets it.

It has been a very difficult couple of months at work, hospital administration has worked hard at increasing hospital volume including the ER. It has worked, we are seeing 25% more patients than a year ago which is good but.......We don't have enough space. The hospital doesn't have enough nursing staff to handle the extra admissions so we are holding a lot which backs us up. At times over half our beds are filled with admitted patients so we are seeing more patients with less beds. Even so, our LWOB rate is lower than ever and we have done an incredible job but the general staff consensus is that we are feeling beaten down and burnt out. The floor nurses never have to break ratio and yet we do it routinely so that the sick people can get the care they need. That is our priority and we all work hard to make it happen. Yay us!

So I am surfing the Internet and reading blogs today and I found this. This guy really gets it, thank you. I hope everyone will read what he has to say.

If you have a family member or friend that is in the medical profession be it prehospital provider, nurse, physician or a member of the extremely important ancillary staff - please take a moment to tell them thanks for the important work that they do. We rarely hear it and it will make a huge difference.

Medblog addict brought up the topic of wearing clean underwear "in case you are in an accident." I couldn't resist telling a few stories of strange things we have found under clothes when we've stripped down trauma patients.

While removing the motorcycle leathers on a rough-looking Harley rider who had crashed we found pink lace women's panties.

On a business man wearing an impeccably tailored suit we found nipple-piercings connected with a chain.

On a ministers teen-age daughter we found a pierced labia.

Your secrets are all laid bare in the trauma room.....literally.

Rattlesnake! (crotalid envenomation)

I grew up in California and always had a fear of rattlesnakes. I envisioned them as evil creatures that would happily leap at you from a rock or chase you through the forest in an effort to bite and kill you. In reality, rattlesnakes are reclusive and most of the bites that we see in the ER are because someone picked up the snake. I know this will come as a big surprise to you, but alcohol is usually involved.

Crotalid venom is hemotoxic which leads to coagulopathies and occasionally thrombocytopenia. Swelling develops at the site, the amount of swelling depends upon the degree of envenomation. in severe envenomations compartment syndrome, massive tissue necrosis, shock from fluid volume shifts into the edematous areas can develop. Deaths are rare but do occur usually from shock. Treatment may require antivenin which costs about $700 dollars a vial, and 5 to 20 or more vials can be used depending on the severity.

So in the last few years we have seen a patient who picked up the snake which promptly bit the thumb. Surprised at the bite, the patient put the snake in the other hand to look at the bite marks and the snake bit the other hand.

One patient thoughtfully put the live snake into a coffee can and brought it to the ER so we would believe him. In case this ever happens to you, we'll take your word for it - honest. The triage nurse, who is afraid of snakes, was rather unhappy to have an angry, hissing snake in her triage room. A lot of consternation ensued as we tried to decide what to do with the snake. One of the security guards ended up taking it to rural property and releasing it as no one could bear to kill the poor thing that had just been minding it's own business when it was rudely picked up by a complete stranger

One patient, in an effort to impress the rest of the people at the party, kissed the snake. That is a bad plan in case you are wondering. Death nearly resulted from airway occlusion. This resulted in a rather lengthy ICU stay. And the ER staff got to practice their emergency crichothyrotomy skills.

Not to be rude, but the people that engage in this kind of behaviour are usually not employed, insured or otherwise able to contribute to the hospital bill costing you, the taxpayers, quite a lot of money every year.

That was not an ONION!

My small rural ER was overrun one night by a large extended family that had all been at a party to celebrate a high school graduation. The meal of Mexican food had been cooked by the graduates younger sister and a foreign exchange student living there as their contribution to the party. They had made taco's, burritos as well as fresh salsa and all the other trimmings.

A few hours after the meal, the party was in full swing, there was a band and dancing. One by one the party goers developed nausea, dizziness and debilitating vomiting. Fearing food poisoning the family all came to the ER. There were thirty-one puking people in our ten-bed ER, all puking copious amounts of beer, wine and Mexican food. I wasn't able to look at Mexican food for years and I'm pretty sure my co-workers felt the same way! Gallons of IV fluids and antibiotics were administered, most of the party-goers ended up going home after several hours but seven of them were admitted for intractable vomiting.

Because of the amount of people sickened and the possibility of food-born illness, the public health department became involved. What was it? Salmonella? Campylobacter? E-Coli? Nope. After questioning the cooks, the culprit became obvious. Daffodils. Yes, you heard it here, daffodils. It seems that daffodil bulbs bear a strong resemblance to small onions. The mother of the cook grew her own vegetables and their home-grown onions were small so the girl mistook a pile of daffodil bulbs for onions. Onions that they put in the taco's, salsa, burritos and guacamole. Daffodils contain a substance called narcissina which acts as an emetic and in large doses can cause collapse, coma and death - although that is more common in small animals who dig up the bulbs and eat them.

That was a celebratory meal that certainly didn't turn out the way it was supposed to. And one holiday celebration that this family would never forget.

A Death in the Emergency Room

A couple in their sixties was driving down the freeway, the wife at the wheel. As she got off at their exit the car skidded a bit on some ice and hit the concrete wall at low speed. When EMS arrived they found the husband unresponsive without apparent injury. The wife, who was hysterical at not being able to rouse her spouse, had an isolated tib-fib fracture. They were extricated from the vehicle and brought to the trauma center.

On arrival, the husband had a glasgow coma score of 4. Three is the worst. His vital signs were fairly stable although the heart rate was low. He was quickly intubated to protect his airway an rushed to CT scan which revealed a massive subarachnoid hemorrhage. From the size of the bleed the physicians felt that he must have had a massive aneurysm in his brain that had ruptured, either from the accident or just coincidentally. The bleed was categorized as a grade V, which has a 10% or less survival rate, from the depth of his coma and lack of response it was obvious that this was a fatal bleed. He was returned to the ER.

Meanwhile his wife, also a patient, had her inital Xrays and her leg had been splinted. She tearfully waited for word of her husband. Being a retired ICU nurse, she had a good idea of the prognosis, if not the diagnosis. But in the human mind hope springs eternal and she hoped he would be OK. The doctors told her the findings. Hope was crushed and she grieved with her family, who had now arrived. She blamed herself, if it hadn't been for the accident he would have been OK. The doctors and nurses told her it was felt that he had a large anuerysm that was a ticking time bomb, if not today then any time. We moved her stretcher into the trauma room so she could be close to him.

His vital signs began to fail and it became clear that death was imminent. She asked to hold him while he died. With some difficulty we helped her lay next to him on the stretcher, arranging the tubes and wires so she could hold him close as he slipped away, surrounded by their children. There were few dry eyes among the staff, despite the size and the activity going on in the ER, somehow everyone was aware of what was going on.

Death in the ER is common. It can be quiet, it can be violent, it can be bloody. An ER nurse has to become hardened to death to survive, we must distance ourselves from the constant barrage of grief and emotion or we would burn out and become unable to function. But that night I was not able to distance myself, I left work emotionally drained and for the first time in a long time I cried in the car all the way home.

The Wonder of Blogging

I've only been blogging for a couple of months and I as surprised at how fun it has been. First I have to say I am amazed that anybody is interested in reading what I have to say. And even more amazing is that people from other countries visit! I have this little site-meter thing and I can look at a world map to see where visitors are coming from. Recently I have had visitors from China, Israel, England, Australia, New Zealand and Saudi Arabia among others. I could've never imagined.
So, I just wanted to say thanks for stopping by. If you were entertained or learned some small tidbit I am very pleased. I'm happy to be a small nursing voice in the blogosphere. I'm sure that sometimes it doesn't sound like it, but I love my job and what I do. I take every opportunity to talk about what I do to people and try to interest them in becoming a nurse, I hope you will to.

Change of shift is up at Emergiblog. Thanks to Kim for doing such a great job.

What in the name of God?

I smelled him before I saw him.

Have you ever smelled a decomposing dead animal? That sickly-sweet aroma that coats the back of your throat? Well that smells good compared to this smell. It was indescribable.

A neighbor had called the police because she thought her neighbor had died and was rotting. The police broke the door open and reeled out of the apartment, gagging. The paramedics were called.

He weighed over 500 pounds. Was a serious drinker, a fifth or more of vodka a day. Had been on a binge for well over a week. Became unable to get out of his recliner so he sat, drinking. Urinating and defecating into the chair. his grossly swollen lower extremities, with their chronic venous stasis ulcers becoming more edematous, weeping serous fluids until fungal vegetations began growing out of the skin. The paramedics said the scene was one of the worst they had ever seen.

I was precepting a new grad. Surprisingly,after this episode, he went on to become a great ER nurse and is one of my favorite coworkers. We gowned and gloved. I taught him one of my favorite tricks, a small dab of peppermint oil on the inside of a mask that will mask some seriously smelly situations. Not this one. We spent two hours cleaning him up as best we could despite the fact that he cursed us and yelled and threatened and was not appreciative of our efforts.

He was admitted, septic, to the ICU. The ICU nurses weren't pleased, who could blame them? The smell had permeated our entire ER, for the entire day we had to deal with complaints from all the other patients. The patient wasn't happy, he just wanted to be left alone with the bottle. He ultimately had severe DT's despite huge doses of Ativan and Haldol, died alone just like he had lived.

The whole episode left me depressed. Just when I think I can't be surprised by how people live I find that I am, surprised and appalled. I still think of this from time to time and while I am greatly bothered by the whole thing, one specific problem is stuck in my mind......

Who had been bringing him his alcohol if he couldn't get out of the chair?

A nursing meme

I've been tagged for a meme by Girlvet. I don't know how this works exactly and I am not going to tag anyone because I don't know who to tag but here goes:

Things I can't live without as a nurse.

1. My ER co-workers. I work with the best bunch of people every. Most of them are my best friends. We work together like a well oiled machine, laugh together, cry together and always have each others backs.

2. My ER docs. We know how important they are and they know how important we are. The head of the doctors groups has gone to administration and stood up for us more than once, often getting the OK for more staff or much needed equipment.

3. The EMS providers that bring us our patients. Despite the fact that most of them are the age of my kids they are fun, damn cute and endlessly patient and friendly to us. I can't say enough how much I respect them and the jobs they do. I have done ride alongs and been in peoples homes and all I can say is "yuck!" I have excellent IV skills but I doubt seriously that I could ever start one while bouncing around in the back of an ambulance while trying not to puke on the patient. (motion sickness) I would trust anyone of them with my life and the lives of my family.

4. Our department phlebotomists. In a cost saving measure last year the hospital got rid of the phlebotomists. It was horrible. This is one of the things that the ER docs fought for. We have our own dedicated phlebotomists and they are AWESOME!!!!!


Happy ER nursing all!

Drug Seeking

The government mandates we turn you into a nation of drug addicts.
When I was just a baby nurse, about twenty years ago, we did not treat people in pain appropriately. And that was bad, resulting in a lot of nursing frustration as well as needless patient suffering.So the government stepped in. They came up with guidelines on pain management. We were instructed to frequently assess our patients pain and accept what they said it was. They had guidelines for appropriate drugs, dosages and administration methods for acute and chronic pain. Patients suffering was alleviated and that was good.With all things the government gets involved in, what was initially good has now turned bad. By insisting that we treat all pain and accept whatever the patient says we have accomplished several things.1. We have told medical care practitioners that their assessment skills are not good. That when a patient walks into the emergency room with a sprightly step, is in the waiting room laughing and joking with their friends, text-messaging on their cell phones and eating that we still have to accept that their pain is a ten. For those of you that don't know the pain scale, ten is the worst you can imagine, like being burned alive. I'm sorry, but people who are truly having severe pain are usually pale, sweaty, vomiting and grimacing. They either hold themselves rigid and very still or writhe in agony. Their heart rate and blood pressure are often higher than normal.2. We have created a nation of people that expect to be given narcotics for every twinge. What ever happened to Tylenol or Motrin? Well everyone says they are allergic to it, knowing that we'll have to give them the stronger meds. Now we have a contingent of people that their sole occupation is to go to different ER's and doctors to get more and more narcotics to support their addiction. These people drive! They think nothing of popping a couple Vicodin, Soma and Xanax and getting in their car to go to the next ER.3. We have taken away the doctors ability to manage a patients care appropriately. Obviously if you pull up a patients visit history and they are seen in your ER 7 or 8 times a month with various pain complaints such as back pain, dental pain or migraine there probably is a problem. But instead of confronting the patient, the MD will usually give them a prescription to avoid the hassles of having the patient complain to administration that they didn't get what they wanted.I'm not proposing that we stop treating pain but let's inject a little common sense. It's pretty pathetic that there is such a large body of people in our country who's sole aim is to spend day after day gorked out on Vicodin, Soma, Baclofen etc. Sad.

Why Does it take Negative Publicity to Make People Do The Right Thing?

I've been reading about the deplorable conditions at Walter Reed Hospital and the way our wounded soldiers are being abandoned. I've read how nurses who have tried to speak out have been fired. Well today I read some good news but wonder why it took all this to get the right thing done? and this is only the tip of the iceberg anyway.