How to make a cop cringe

We get a lot of patients brought in by the police for clearance to go to Mental Health. Clearance includes labs and a urine drug screen. If the patient won't cooperate we insert a catheter to obtain the urine. Most patients are cooperative, but the is always one or two that have to be jerks about it.

One day the police brought in a guy who arrived in the ambulance in four point restraints and was completely agitated and obnoxious. We gave him a shot and the two police officers who brought him in were staying for our safety until he calmed down. The nurse went in and with their assistance as well as extra staff to restrain him, cathed him for a urine sample. The guy was hollering bloody murder before she even started. The funny thing was the cops, when she inserted the foley they turned as pale as ghosts.

As everyone left the room one cop was overheard saying to the other: "That was the worst thing I have ever seen."

Now don't get me wrong, I don't have anything against urologists but they are the only specialty that has come near to making me faint, not once but twice.

The first time was a sickle cell patient with priaprism. I gathered the needed supplies, 10 and 35cc syringes, needles of various sizes - including BIG- and a large bottle of lidocaine.

Not knowing what to expect I went into the room with the Urology resident to assist. First he stuck a needle in the penis to draw out some blood for testing. When the results of that were back he started injecting local into the penis. The poor patient, despite some pretty bit doses of Versed and Dilaudid, was hollering. I was starting to feel a little odd. Then the resident took the large syringe and started sticking it into the penis and aspirating out the clotted blood. He had done this about 4 or 5 times when I suddenly broke out in a cold sweat and was overcome by a wave of dizziness. Knowing I was close to fainting I left the room quickly and sat down out in the hall. The resident, and the patient thought it was all quite funny.

The second time was a prisoner who had a hydrocele repair and then developed a scrotal hematoma. The prison didn't send him in right away so by the time he got to us his scrotum was the size of a volleyball. he said it wasn't painful, just bothersome. So here comes the urology resident, as luck would have it - the same one from the other patient. He makes a small incision and starts squeezing the scrotum between two hands, expressing tons of clotted blood. When the blood stops coming out fast enough to suit him he sticks his finger in the incision and digs around, breaking up more clots. Clots of all sizes, big and little. The patient seemed unconcerned, stating it was a little uncomfortable when he squeezed but not painful. About the third time the resident had his finger in the hole digging around I once again started to feel faint and had to leave the room.

I worked at that hospital for three more years and every time I saw that resident he teased me. I still give the urologists a wide berth.

Stupid things that JCAHO comes up with to waste our time.

National patient safety goal #2e , communication, states that the institution will come up with a standardized method of patient hand off including the opportunity to ask questions.

To meet that goal it is expected that each time that patient care is handed over you must give a report and the person taking the patient must be given a report and asked if they have any questions. Duh. Don't we do that already? do you know of any nurse that just grabs her things at shift change and leaves, expecting the oncoming nurse to figure it out?

Oh but wait, JCAHO means EVERY hand off. And it must be documented. So at change of shift report I must chart "Report was given to Susie Smith RN, It was very thorough including a review of all the labs and medications as well as the patients responses to them. We discussed the patients fall risks, accurate weight, preferred method of living, alcohol intake, social concerns and family dynamics. We reconciled the patients medications even though they have no idea what they take, they are a VA patient and it is after hours so the clinic is unreachable and they get all their medications by mail. We reviewed all the doctors orders for completion and double signed all meds handwritten on the MAR. I then gave her the opportunity to ask any questions which was ignored because she was too busy flirting with the new intern."

Susie Smith RN must document "Report received, all my questions answered to my complete and utter satisfaction." Two pages of complete drivel would have been charted taking 30 minutes that could have been better spent at the patients bedside caring for the patient. Oh, I know this is a bit of an exaggeration, but you get the idea.

And here is the clincher, this isn't just nurse to nurse, it includes handoffs to the radiology transporter etc. etc. etc. and when we get the patient back. And our lunch and break relief person.

So lets review. JCAHO is going to require a complete medication reconciliation form on every patient that comes to the ER, they already require a weight, asking about advanced directives, smoking cessation teaching, asking about flu and pneumonia shots, identifying the patients preferred method of learning, drug and alcohol abuse screening, asking if the patient is a victim of domestic violence, determining if they have any financial or social concerns and now.......the friggin' patient hand off.

So with all these requirements I figure I will have time to care for about 3 patients in a 12-hour shift. My ER sees around 100 patients a day so we will need approximately 30 nurses to carry this off. Oh, and let's not forget the pharmacist who will have to live at the Pyxis to OK all of our meds before we give them. Good grief. Does anyone besides me see the idiocy in all of this?

Pneumococcus

She was 20. Her boyfriend drove her to the hospital but she was too weak to get out of the car. One of our ED Techs went out with a wheelchair to help her, I went along to see if he needed help. She was guppy breathing, eyes sunken and unfocused - telling of a struggle to breathe that had gone on too long and was about to end. A few quick questions to the boyfriend while we lifted her out of the car and ran her in to the trauma bay just inside the door revealed a short history of feeling unwell, she was not an asthmatic but the shortness of breath had started this evening and progressed rapidly. They didn't have any money and she wouldn't allow him to call an ambulance.

"I need some help in here, get a doctor, call respiratory with a vent and Xray. Someone get an RSI kit." Nurses and techs ran in all directions. Once on the gurney we cut off her clothes. She was profusely diaphoretic, more evidence of the struggle for oxygen. Her oxygen saturation was 73%, no air movement was heard over her lung fields. The respiratory therapist arrived and set up for intubation. Another nurse got IV access and started some fluids running to carry the drugs we would be pushing shortly. RSI (rapid sequence intubation) meds were drawn up - Succhinylcholine to paralyze the muscles so the patient can't bit down or fight against being intubated. Etomidate, a potent anesthetic that rapidly induces unconsciousness, Vecuronium
another medication that causes paralysis that is given in a small dose to counteract the muscle fasiculations that Succhinylcholine causes, fasciculations that can lead to vomiting and aspiration.

The meds were given and the doctor inserted an Endotracheal tube into her trachea which would allow a ventilator to breath for her. This is done when a patient can't breathe effectively on their own. The respiratory therapist passed a thinner tube down through the ET tube and suctioned her lungs, removing copious amounts of bloody pus. (in the medical world we call that purulent blood tinged secretions.) A specimen of this was sent to the lab for identification of the organism causing this horrible pneumonia, although from the rapid onset and severity it was presumed to be Pneumococcus.

Pneumococcal pneumonia causes death in up to twenty percent of it's victims. It is unusual in such a young person but this patient had a splenectomy in the past which left her more susceptible to infection.

Powerful antibiotics were started. An Xray showed tri-lobar pneumonia, three of her lung lobes completely whited out with infection. Her blood pressure plummeted, probably from endotoxin release when the antibiotics started killing bacteria. Vasopressors were hung. Taking care of a critical patient is like a ballet, every nurse moving separately and yet together, mixing and hanging powerful, life saving drugs. Calculating critical dosages and monitoring the effect of the medications they are delivering. It takes more than one nurse to stabilize such a patient, one may be mixing drugs, another hanging drips and titrating dosages, another writing down what is being done. In-between all the technical stuff you are caring for the patient and their family.

As soon as her blood pressure was stable enough we transported her to the ICU, where she had a very long and complicated stay, over four months. We left and went back to the runny noses and sprained ankles, listened to people gripe and complain about their waits and thought "you just don't know how lucky you are to be able to complain." But of course we didn't say it.

Mystery Man

I worked at a large county hospital a few years ago. Triage there was a nightmare, it was not uncommon to have to triage 80 or more patients in 8 hours, you do the math but I figure that gives you about 10 minutes per patient which sounds OK until you consider about 1/3 to 1/2 were little, squiggly kids that had to be weighed and a full set of vital signs, including a rectal temp, obtained on each one. The beds in the back, including the permanent hall beds, were always filled so you better have a damn good reason for asking the charge nurse for a bed. Wait times for triage on a busy day could be up to two hours and wait times to get to the back averaged 6 hours - if you were sick. As a consequence, the lobby was full of angry people most of the time. The chairs were always packed and the noise level was unbelievable at times, small kids shrieking and crying, TV blaring and 100 or more people talking, crying, moaning and yelling. There was usually a line of people at the greeter window waiting to check in.
Triage in this place didn't just involve triaging the patients, you had to eyeball the cards each time and try to discern from what the greeter had written on them (some of the greeters didn't speak English all that well) who was actually sick and needed to be seen first. And then you had to eyeball the waiting room and the lineup at the window and do the same. It wasn't uncommon to find, amongst the loud, angry, throng - someone who was truly ill. For some strange reason, the critically ill will often drive themselves to the hospital and sit and wait quietly while the hangnails will yell at every passerby because they have had to wait.

One night was especially bad, the waits were up to 12-hours to be brought back to a room. The lobby was bursting at the seams, patients spilling out into the parking lot. It was one of the worst shifts I have ever worked in my career. There were multiple trauma that night from a bus crash on the interstate, an outbreak of rotavirus had the peds side filled with kids getting IV fluids and we were still seeing a lot of patients with flu. Our 8 permanent hallway beds had expanded to 16 hall gurneys and 10 hall chairs. The hospital had gone to internal disaster to get extra staff in. Several of the ER nurses were going on 16 and 20 hours.

Toward early morning we were starting to get our heads above water. The lobby was less than a quarter empty. The triage nurse realized that the elderly man with the raincoat and fedora had been sleeping in the same chair for quite awhile, worried that he had been one of the patients that hadn't answered when called she went to wake him and check on him. She said "sir?" several times but he didn't answer so she shook him. Horrified, she realized that he was not only dead, but had been so for quite some time.

There was an investigation and it was found that he had never signed in. It was never determined if he had come in an felt too bad to stand in line and had sat down to rest or if he had come in to visit someone and died while waiting. With his hat on and his chin slumped forward onto his chest, no one had thought he was doing anything other than sleeping. How many people had sat in the chairs next to him and not noticed he was dead?

How sad to die that way, alone and unnoticed.

Change of Shift

Change of shift is up at Blissful Entropy please take the time to check it out and be amazed that all this was done while the author is busy getting ready to open a brand new ER.

The Collapse of Emergency Medicine in America

Yes another JCAHO rant. I received an Email from ENA this week to discuss the JCAHO mandate that all patients in the Emergency room have a medication reconciliation for filled out. They have also mandated that all medications given in the ER must first have Pharmacist approve it. AND, we must document the time we start an IV and stop the IV. What does this mean to you?
The added burden of documentation and the waiting for a pharmacist will add an average of two hours to each and every ER visit. This added time will further bog down a system that already can't handle needs. The nurse, who is already spending 50% or more time on paperwork will be spending even more time away from the bedside. Since each patient will be in the department longer and the nurses will have less time to spend with them we will need millions of more nurses in a country where a severe nursing shortage exists and is getting worse every year as our nursing forces reach retirement age. Factor in to that the millions of nurses that will quit nursing in disgust and move to Costa Rica to live life on the beach. The hospital will have to hire even more people who carry around clipboards and whose sole purpose is to make sure that all the paperwork is properly filled out, adding to already bloated administration instead of adding to the bedside. For the ER doc it means that less people will be processed through the department greatly reducing your income and if you live in California, the governor wants to take two percent of your income to cover non-reimbursed medical care that you are already providing for FREE!
The ER nurses are homicidal and the docs are suicidal which will put an added burden on the collapsing prison systems and the non-existent mental health system.

THE MADNESS HAS TO STOP! Why are we allowing this ridiculous, bloated, self-procreating bureaucratic idiocy to continue? Remember the IRS a few years ago? Out of control with no oversight of their operations? Hello? It is happening all over again, it is time to stand up and JUST SAY NO.

AMEN sister!

Please take the time to read this post at Emergiblog. It is just another example of the bloated, bureaucratic idiocy that is JCAHO. First they try to tell us we have to stop ER overcrowding. Since that was an abject failure now they come up with this asinine idea which is guaranteed to add to the problem of overcrowding since it will add at least 1/2 hour and often more to each patient who receives a medication stay.

ENA has vowed to fight this, I'm behind them all the way. ENA, the check for renewal is on the way.

Thanks Kim, for using the power of your blog to educate people on this.

JCAHO already is a joke, they just don't know it.

Knowing my Place

I recently read a post at N=1 that has my back up.
Let me start off by saying I read N=1, this is a blogger that has some powerful things to say. And I have no intention of starting a blogosphere war. But I am angry at the statement that because I chose a certain name, which happens to be my nickname in my family thank you very much, I am denigrating nursing as cartoonish. How dare you?

I am a damn good nurse, I hold certifications in Critical care and Emergency nursing. I have mentored many new nurses who are now damn good nurses. I am respected by my colleagues, including the doctors I work with, for my experience, skill and knowledge. I want what is right for my patients and will go to great lengths to see that they get the care that they require. I am not afraid to stand up to administration, in fact I am rather well known for that. I have made some very distinct and positive changes in the way of procedures and staffing at the last two hospitals I worked at because i am not shy about fighting for what I believe in. I take every opportunity at work and in the community to make sure people know exactly what a nurse does and why we are so important. In no way do I believe that I am inferior to the Physician, I perform a different role in the team and therefore have as much value as any team member. I demand respect and I give respect to my fellow team members in return.

If nurses are feeling undervalued, denigrating the physician is not the way to improve our lot in life. We are undervalued because we permit ourselves to be. We need to educate the public as to what we do. We need to join a strong union to force hospital administration to treat us with the respect that we deserve. We need to stop backbiting like a bunch of high school girls and stand together. When we are strident and bitter the opportunity to get the message out there is lost because people will turn away.

I didn't choose my blog name to pimp myself as i have been accused. My blog is mine, it's personal like a diary. If others choose to read it, great. If they don't, fine. For those that read it thanks, I hope you enjoy yourself. If you don't like what i have to say then don't come back.

Sometimes they do lie

I have a firm policy that people who are going to receive narcotics and be discharged home must have a designated driver in the room before I administer the medication. Non-ER people probably think this is terrible but those of us that work in the ER understand.

A few examples:

A patient tells me that his ride is waiting in the parking lot. "OK sir, do you really expect me to believe that your ride is sitting outside in the car when it is 118 degrees out there right now?" Not to mention that this was a disabled State Trooper.

Me: "Do you have a ride?"
Pt. "Yes"
Me: "Where are they"
Pt: "She's being seen also"
Me: WTF?
This woman had driven 121 miles to our ER bypassing three other ER's because "she didn't like the medical care there." Her designated driver had also signed in for 'back pain.' I discussed the problem with the ER doctor and he discharged them both without any treatment after a stern warning not to return.

Patient with anxiety was given Ativan IV by another nurse after telling the nurse she would call a cab. When no one was looking, the patient snuck out the back door but was caught pulling out of the parking lot by the security guard who warned her to pull back in the parking lot and when the patient did so they hit another parked car and ran over a sign. It always looks good to incoming patients when someone is being handcuffed and arrested in the parking lot.

Another patient with anxiety from a city six hours away. The story is that the family is traveling and the patient is out of meds. The doctor gives 2mg of Klonopin which the patient states is the regular dose. He warns the patient someone else must drive. The wife states she will be the driver. The nurse instructs the patient he must have a driver before giving the med and the wife, once again, states she will drive. The med is given and they leave. Soon we get word there is an accident, two victims on backboards. The driver has passed out and rear-ended another car. The driver is the previous patient, the one who promised he wasn't going to drive. Thank God for good documentation, it will save the Doctor and Nurses butts on this one.

Paperwork

What follows is another JCAHO/EMTALA/DHS/CMSP/HICFA etc. rant. Please feel free to skip it if you will be bored.

I spent fully 75% of my day today doing paperwork. I had two medication reconciliation forms to fill out that took me over 45 minutes to complete as well as multiple phone calls because the patient had no idea what medications they took, the MD's were unreachable, their families non-existent or dumber than dirt and their meds filled at a total of 7 different pharmacies. I had to do a checksheet to prove to JCAHO that I observed 5 nurses properly putting armbands on their patients and taking the MAR into the room when administering medications. I had another check sheet to prove to JCAHO that we checked all the crashcarts daily for outdated medications and supplies (c'mon, this is an ER for God's sake. We use those crash carts so much the supplies don't even get a chance to get dusty.) I triaged 16 patients (please note I was not the triage nurse, this was just accepting ambulances and helping out other nurses.) Thanks to the fact I have to ask every patient If they have had a flu shot, pneumonia shot, tetanus shot, drink alcohol, have an advanced directive, suffer from domestic violence and what their preferred method of learning is, triage now takes 10 minutes instead of 2. That equals almost four hours. Then I had to fill out a check sheet to prove that I checked all the outdates on the meds in the three RSI (rapid sequence intubation) boxes. Never mind that we used all three of them yesterday and replaced them with new ones. I had to fill out a restraint flowsheet to prove I checked my patient every 15 minutes. All this added to the burden of documenting the care I provide to my patients. For every hour providing care 2 to three hours are spent generating reams of paperwork to satisfy the government regulatory agencies.

JCAHO's mission statement should be "Paperwork before patient care."

It has to stop. None of this paperwork equals better patient care. In fact, taking the nurse away from the bedside ensures a higher morbidity rate. This has been proven by many government funded studies. Now isn't it asinine that they will do a study that shows nurses at the bedside improve patient outcomes and then heap so much paperwork on us that we can rarely make it to the bedside.

Hospital administration is all about patient satisfaction scores. Let me help you. A satisfied nurse makes a satisfied patient. Seriously, doesn't this seem pretty basic? Why don't they get it? A nurse at the bedside that has the time to teach patients, listen to their concerns and fears equals patient satisfaction. Nurses want to feel that they are giving good care, they way things are right now, we rarely do.

BTW, if you don't hear from me anymore I've been rounded up by the FBI and take to some secret federal lockup somewhere.

Sometimes they don't lie

If you read ER blogs you'll will notice that we have to deal with some patients who aren't telling the truth, it tends to make us cynical. But there are many times when the patient is very obviously telling the truth, here are a few.

Patient presents to the greeter window with a chief complaint of "I've been stabbed" since the handle of a steak knife was protruding from just under the right eye, it was obvious he was correct. He drove himself to the hospital, was completely calm and complained of pain "3." Frankly looking at the knife gave me sympathetic pain of a "7" He was extremely lucky, the knife had penetrated his maxillary sinus and into his brain but he was very stable, recovered easily from surgery.

"I've cut off my finger" Yep, he had, it was in a plastic bag. He, too, had driven to the hospital and refused pain med other than the local.

"Do you think it is broken?" The forearm in question was shaped like an 'S'....."yep"

"I'm vomiting blood" this one thoughtfully brought his 2 gallon bucket that had about 2000cc of blood in it so we would believe him. He was sheet pale with a pulse of 140, we probably would have figured it out but appreciated the thought. He had been vomiting from a night of heavy drinking and suffered a Mallory-Weiss tear to the esophagus which resulted in some dramatic bleeding. Poor guy, he was scared senseless........I wonder if it kept him from drinking for awhile (college kid, not long term drinker.)

A word about the ER greeter. Most ER's I have worked in have a window that the patient presents at to get signed in. Behind the window sits a member of the registration staff. These people are at the front line of the ER facing the crowd and put up with tremendous abuse at times, God Bless them. However, they do get a little excited when a patient like one of the above come to their window.

Blood transfusions

The chief complaint was 'shortness of breath'

the patient is sitting in front of me in the triage room was the color of a sheet, a color that was even more alarming given that she was Indian. She was so colorless that even her lips had disappeared. I skipped the rest of triage and took her back to a room.

On the monitor she was slightly hypotensive and tachycardic. Obvious to us, profoundly anemic. IV access was quickly obtained and blood drawn for testing and to crossmatch for blood transfusion. Her blood was like red Koolaid instead of the thick opaque substance usually seen. Bedside testing showed a Hemoglobin and Hematocrit of 2.5/10.9! Normal for a woman is 12-15/35-47. History reveals a forty year old woman with dysfunctional uterine bleeding for months, heavy periods that last two to three weeks out of every month. Her and her husband are dairy farmers, running a small dairy farm that is barely breaking even. There is no money for insurance but on paper they have to much to qualify for medicaid. So she hasn't seen a doctor, not being able to afford one. Only now have the symptoms becomes so severe that she was brought in by her distraught husband.

She was admitted for transfusing and further testing which revealed large fibroids, she underwent a hysterectomy and went home after an uneventful recovery.

There are a lot of pro's and con's regarding universal health care but I know one thing....In a land this rich, there is no reason for this to happen. This was a woman who had worked hard all her life - 16 hour days, 7 days a week, to make a living and she couldn't afford basic medical care. Right now there are millions of people who are able bodied but have chosen to be slackers and they get a free ride courtesy of the government. Where is the incentive to keep working if you can quit your job and get welfare and medicaid and spend your days doing as you please?