Change of Shift: Volume 1, Number 25

Another fine edition of Change of Shift is up at Emergiblog, hosted by Kim.

I am not terribly computer savvy, it took me several weeks to learn how to embed a link in a post and even longer than that to get more than one picture in a post. I am in awe of the people that host the Blog Carnivals and the incredible amount of work put into to them to make it not only visually appealing but entertaining and educating as well. Great Job Kim *Applause*

Oh no!

This is bad news.

Grand Rounds

Memorial day Grand Rounds hosted this week by From Medskool. No special theme, just a very nice collection of posts.

A WTF moment

Sometimes we find out things that didn't happen that scare us half to death.

for instance, I was taking care of a psych patient one night that came in with "thoughts of hurting others." He seemed anxious but responded well to 1mg of Ativan and was resting quietly on the stretcher waiting for the psych resident to come and evaluate for admission. I wasn't impressed, the guy didn't seem to be in crisis and we had a revolving contingent of homeless people that came in with psych complaints just so they could get a 72-hour admission with a warm bed and three square meals a day. I figured this was more of the same because I remembered taking care of the same patient last month.

When I had a few moments I read the psych residents note from the last admission. One paragraph in the history and physical really startled me. The patient had told the resident that he had been overwhelmed with the desire to grab the nurses pen out of her pocket and stab her in th eye. That nurse had been me!

In the business of our every day routine we sometimes become complacent. To this day I never enter any room with anything on my person that could be used to injure me. I've become much more aware of what is going on around me. But I have to wonder, how many other things almost happened to me, and others, that would have changed our lives forever?

Memorial Day

Please spend this weekend thanking the members of our armed forces, past and present, for their incredible efforts and personal sacrifices to keep our country free.

No matter what you think of the current conflict in Iraq, the truth is we can worship in any way we wish without fear. We can criticize our government without retaliation. You can freely disagree with me and I with you without fear of imprisonment, torture and death.

Thousands of men and women have died fighting to maintain our freedom, on foreign soil, far away from their loved ones. So while you are firing up the barbecue take time to thank Grandpa for fighting in WWII and Uncle ED for Vietnam and Cousin Sue for her time in Iraq. Thank those service members who, even though they remain on American soil, provide support services and back up for those overseas. Thank the families of deployed servicemen for doing without Dad, Mom, Husband, Wife or Child.

While you are waiting for you burgers to cook drop a line to your legislators and Governor demanding improved conditions for our wounded service men and women who do not deserve to be failed by the country that they fought to preserve.

And please remember, Alcohol and anything with a motor is a bad combination.

Happy Memorial Day America.

What the heck did this guy do?

Many moons ago I worked in an ER that treated the prisoners from the local Maximum security prison.

The prisoners always came in leg and arm shackles which weren't removed during their stay. That made starting an IV etc. kind of a challenge but you learn to adapt.

At first I was nervous taking care of the prisoners, being at a maximum security usually meant murderers or worse, but the reality was they were always quiet, soft spoken and extremely cooperative with us.

You could kind of tell the seriousness of the offense by the number of guards that escorted the prisoner. The usual was two so that there was always at least one at the bedside if the other guy had to use the restroom. Once in awhile three, which meant either it was a severe crime or the guy had tried to escape before.

One day I got a prisoner that was coming in for evaluation of infected decubs (decubitus ulcer or more commonly known as bedsores.) This particular patient had been incarcerated in the hospital cell block for years. He had multiple CVA's (strokes) and had a trach and a PEG tube. He was completely aphasic and had no purposeful movement of any of his extremities. His arms and legs had contracted him into a permanent fetal position. Basically he was in a permanent vegetative state. He arrived in shackles with FOUR guards. Yes, four. The only prisoner that I ever saw do so.

I don't know, he didn't look like a huge threat to me. Personally I felt that whatever atrocity he committed was partially negated by being forced to live like he was. He didn't appear to be much of a flight risk but I guess they weren't taking any chances that he was faking (for 13 years.)

ER docs

One of the reasons why I chose to work in the ER involves the different relationship we have with the doctors we work with. We spend hours together daily and are good friends for the most part. We know each others strengths and weaknesses, trust each others skills and a hold an enormous amount of respect for each other. For the most part we are a very close knit team and have a lot of fun together. You don't see that on the floors, the doctors only round for a couple of hours every day and don't get to know the nursing staff. It makes a big difference in how the nurse is treated, as a valued team member or as an inferior.

The ER is a very emotionally and psychologically draining place to work. We cope with that by a lot of joking around and playing pranks on each other. It's a way to lighten up and let go of some of the tension.

One night, it wasn't very busy and our doc was back in the break room eating dinner and watching CNN. The tech got the idea to make a fake patient, so he got some hospital pajamas and stuffed them with towels, covered up the 'patient' with a blanket and put a knitted hat on pulled down low on the 'head.' The chief complaint was 'rectal foreign body.'

The charge nurse went into the back and told the doc there was a patient and what the complaint was. He grabbed the chart and headed into the room. We surreptitiously gathered around. He walked into the room, introduced himself and started to ask questions, of course the patient didn't answer so he goes, "sir? Sir?" and when there is no response he walks closer to shake the patient and sees that it is fake. By now the whole staff is rolling around with tears streaming down our faces from trying to hole in the screams of laughter. The poor doc laughed so hard that he cried, at one point so helpless from laughing that he was draped across the counter. Later, when he had recovered he vowed revenge. That hasn't happened yet, but I have no doubt it will.

But all joking aside, I know when I tell one of my docs that I am worried about a patient and I need them to go see the patient now that they will do just that, no questions asked. Because they know me well enough that when I am worried, they are worried.

Recruitment and retention

Hospitals spend a lot of time and money on recruiting nurses. A lot of the nurses they recruit are inexperienced new grads.

At the same time they do nothing to keep their experienced staff happy so they often leave seeking greener pastures.

Why not spend a little time and effort keeping your experienced nursing staff which is your best resource? If your staff didn't keep leaving you wouldn't have to spend so much money on recruitment.

Duh.

Grand Rounds

Grand Rounds is up at impactED nurse, great job! Please take the time and check it out, an incredible amount of work goes into hosting grand rounds so make sure to leave a comment with your thanks for the job well done.

Patients Rights

There is a poster hanging in the ER waiting room with the patients bill of rights. I'd like to point out that the patients bill of rights DO NOT give you the right to:

Call me a "fucking bitch" or any variation thereof. I may be a bitch but you don't know me well enough to determine that.

Spit at me, kick me, pinch me, crush my hand, punch me or throw the tray off the mayo stand at me (yes I have experienced all of these.)

have your visitor stand in the doorway of the room glaring at all the staff members that walk by

Ask me to "wipe you" when presumably you manage that by yourself at home

Stand by the sign that says 'No Cellphones allowed' using your cellphone.

Take pictures of other patients in their rooms with said cellphone.

tell me your pain level is a "10" when you are so somnolent that your oxygen saturation dropped to 77% and I had to shake you vigorously to wake you up and make you take deep breaths.

Steal the drugs out of the crashcart drawer. (Good thing I caught you, injecting some of those meds would cause much unpleasantness including death.)

Steal the supplies out of the room, band aids, tape, culturettes etc. (what in the heck were you planning on doing with the culturettes?)

Steal the electronic thermometers, phones, Doppler, light source for the speculum etc.
(no matter how careful we are this stuff disappears on a regular basis.)

This is just a short list. Feel free to leave me a comment with any suggestion for this list.

Jungle land

One night the police brought in a patient who needed a mental health evaluation and hospitalization. The mental health situation in our county was dire, only 15 inpatient beds and they were always full so it was next to impossible to get a patient accepted there without hours and hours of jumping through hoops. Not only that but once you sent them there they were often released so fast that you'd see them on the streets driving home from work that day! Those fifteen beds were all that was left open in a huge psychiatric facility that, in its heyday, housed over 1500 patients. Those same patients, instead of just being warehoused, lived as productive a life as possible. They ran their own farm to grow their own food. They had their own dairy and sold surplus milk to raise money for trips and special things. The patients worked in the kitchen and the laundries. Now it is all shuttered and spooky, the huge buildings looking like something out of a Gothic novel.

This patient was five feet wide and five feet tall. Butt naked, drunk and belligerent, had tried to kill himself by slashing his wrists and then barricaded himself in his house and kept threatening to shoot the police. Why was he not in jail you ask? Welcome to my world. The jail will not take someone who is 'suicidal' for fear they will manage to harm themselves while in police custody and make the jail look bad. I understand that really I do but why dump them on the ER where they will sit for hours or days taking up space where someone who is sick could be taken care of.

Anyway. The patients nurse was new to the ER, a med-surg nurse who wanted a change. He was a very nice guy but kinda shy and soft spoken, not the usual kind of personality you encounter in the ER. He got flustered and embarrassed easily but was coming along and we had high hopes for him if he could just toughen up a little.

We were busy that night and not really paying attention to what was going on with this patient until we got a shout for help from the nurse. We got to the doorway of the room and all stopped short of entering. The patient had gotten out of his restraints and was crouched in the corner of the room, still butt naked, hugely obese and sweaty from a couple hours of fighting against the restraints. He was gesturing at us and shouting...."Come on, I'll take you all on." then he looked at his nurse and said "you first - you girl in guys clothing." That was the moment a real ER nurse was born. That nurse, along with several PT aides rushed the patient. For a few moments there was nothing to see except a pile of staff members and flailing limbs, but when it all cleared the patient was back on the gurney in four point leathers shot full of Haldol and Ativan.

Later on, one of the patients said, "it's like working in jungle land here, wrestling with the wildlife."

8 Random Things about Me!

I forgot that Girlvet tagged me for a meme, 8 random things about me. Hope I can think up eight, I'm kinda boring.

1. I like to read, a lot. I am usually reading 4 or 5 books at a time - I have one in the kitchen I read while I am eating, one by my bed, one in the car, a couple in the living room. I read such volumes of books that I can reread my favorites in a year or two and it is like reading a new one almost.

2. I drive a minivan, boring I know but you can't beat it for trips with the kids and dog, everyone gets their own seat (including the dog) and can watch DVD's to pass the time.

3. I am addicted to HGTV, any show dealing with forensics and Dancing with the Stars.

4. I don't believe in organized religion. I do believe in God but throughout history some of the greatest atrocities were committed in the name of religion. (Witch hunts, Jihad or Inquisition anyone?)

5. I have been in every state in the continental US

6. I have lived on both Coasts.

7. I cry at Disney movies. When we get to the sad parts I can feel the kids looking over at me waiting for the entertainment.

8. I love a good microbrewery beer. Whenever I go someplace new I always check out the small breweries. I especially love the ones that have attached restaurants. You can get some damn good food sometimes.

That was a lot more difficult than you would think. I'm not tagging anyone but feel free to participate if you want.

Change of Shift: Volume 1, Number 24

Change of shift is up at Nurse Ratched's Place, the theme this week is nurses who inhabit the television airwaves. Too bad there aren't more nurses on TV. And too bad the ones that are on are always shuffled to the background or made to look like sex kittens, I don't know about you but I passed the sex kitten stage many years ago, not that I ever really fit that stereotype anyway.

I think the public needs to know what nurses do. For instance, when you are in the ICU - critically ill, on a ventilator and multiple drips to maintain your blood pressure and pulse, TO KEEP YOU ALIVE! Who do you think is monitoring you vital signs, calculating drug dosages and titrating those drips? A nurse. Who do you think is turning you frequently so you don't get bedsores or develop nosocomial pneumonia? A nurse. Who do you think is alert to the most infinitesimal change in your status that needs to be addressed to keep you alive? A nurse. When the doctor isn't in the hospital who do they depend on to let them know what is going on with the patient? A nurse.

Nurses, get out there and tell people just what it is that you do every day, don't let them keep thinking that all nurses do is give bed baths and fluff pillows. After all that is what they see on TV.

Witnessed on a t-shirt

Too much emergency medicine interferes with natural selection.

Grand Rounds

Grand Rounds is up at Med Humanities and I am thrilled to have a post included. The hosts put in an incredible amount of work and do a great job. I hope you will stop by and enjoy the posts included this week. Next weeks edition will by hosted by Ian at ImpactED Nurse
one of my favorite blogs.

Having a Baby

There is a law in California that a woman may leave a newborn at a hospital, police station or firehouse and not suffer any consequences. Several states have similar laws that were enacted in an effort to reduce the amount of abandoned newborns who end up dying.

A few years before the safe haven laws, I was working in a small ER in a town with several colleges. One night we got a call from an ambulance bringing in a female college student, pregnant for the first time with a history of labor for 2 hours. No prenatal care.

ER nurses hate childbirth. It is not something we are skilled in and it makes us very uncomfortable. We were hopeful we'd be able to get this girl up to OB after a quick check, after all - how far along could she be after being in labor for two hours?

when the ambulance arrived they were accompanied by the girls room-mate. The story was that the roommate began to panic when the girl started freaking out during contractions and called 911. She told us that the girl had been successfully hiding her pregnancy, she was a very thin girl to begin with and starved herself so she wouldn't gain any weight and wore loose clothing.

Now we are beginning to get a little worried, this girl had no prenatal care and obviously didn't want the baby and hadn't taken care of herself during the pregnancy - who knows what kind of shape the baby would be in? All the more reason to get her up to OB. A call was put out to the OB doc on call and while we were waiting for him to return the call the doc went into examine the patient. All of us were in the room, starting an IV, obtaining vital signs. She was moaning and writhing with contractions which were happening about every 2 minutes, not a good sign. That became even more evident when the doctor did the vaginal exam and found the babies head on the perineum. The baby was born in the ER just 10 minutes after her arrival, fortunately healthy, apparently full-term but small for dates, most likely from moms poor nutrition.

After the baby was born the mom turned her face to the wall. She refused to look at the infant, stating that she didn't want "it." The OB doc came and delivered the placenta and they mom and baby were taken upstairs. We heard that the baby was given up for adoption and the mom had refused to ever see it.

We always wondered, what would have happened to the baby if the roommate had not gotten scared and called 911? Thank goodness we never had to find out.

ER in Crisis

A grim portrait of the reality that is the ER. Emergencies are in crisis and it is only going to get worse. Picture yourself working in this situation trying to do a medication reconciliation form on each patient, waiting for the pharmacist to OK each medication before it is given and documenting each IV's start and stop time. Get real JCAHO, join us in the real world.

Grand Rounds

Grand rounds is up at The Blog That Ate Manhattan and once again I am pleased to be included. It's a kick to check the little site meter thingy and see that you've had a lot more traffic than usual and realize why. Please make sure to check it out and enjoy all the great posts from all manner of blog authors.

The theme of my day was: Sllooowwwww

Here is how my day went:
Patient number one: 22 year-old female with right lower quad pain and dysuria. Bring her to room and obtain urine which I send for UA which is back and on chart before patient is seen and is positive for UTI. Orders? IV 1000cc NS bolus, labs, blood cultures, cardiac monitor. I ask about the monitor on a healthy 22 year-old and am told it is because she is tachycardic (118, and she has a temp of 101.) I mention we can keep track of the pulse by doing good old vital signs but am getting nowhere so I give up.
One hour later, labs are back and there is minimal elevation of her WBC's and few red blood cells in her urine. Now there is an order for a CT scan with oral contrast. Why? Well she may have an appy and she may have a kidney stone so we will do a scan to rule out both. Oral prep takes an hour and a half to give and then it takes an hour to get the results (if we are lucky.)
Three hours later we finally get the CT results back, normal. Now there is an order for IV levaquin which takes an hour to infuse. What? We couldn't have been doing that while waiting for the CT? Arrgh!!!!! The patient has been here for four hours and now we are going to start an antibiotic.

Patient number 2 came in with shortness of breath, bilateral lower extremity edema to her ribs with 4+ pitting. Has a cardiac history and COPD. Got the usual workups for both. BNP, which is an indicator of severity of CHF was tremendously high (DUH!) at 2400. Now that workup is complete we give IV lasix to try to get rid of some of the fluid. We watch her diuresis for 2 hours. She urinates about 1 liter but still is in distress. Now she has been in the department for five hours. Now we need to try to ambulate her to "see how she does." She does crappy, sat's drop into the 80's with oxygen just getting out of bed. She lives alone and is very weak. So now we have to call her MD and wait for him to come in and admit. Over all, she was in the department for 7 hours and 45 minutes.

Patient number 3 came in with the police on a 72 hour hold for med clearance. It took 2 police, 2 security and 4 nurses to get him restrained and medicated enough that we could even draw the screening labs. He was still there when I left. With the state of the mental health services in our community he probably will be there tomorrow when I return.

So basically that is how the day went and that is why I am sitting here drinking an ice cold Corona with lime right now. How was your day?

Code Talk

Check out this post at Dr. Edwin Leap's blog, it is very funny. I'd love to use some of these on the radio.

Femur Fracture

Someone asked me to put an end to the painful penis stories (jokingly) so here is a story about a guy with a femur fracture. The femur is the long bone in your thigh, it is incredibly strong and takes a great deal of force to break. When it is broken there is also a good likelihood that the patient will have other injuries from the same force so they will need a careful trauma exam. Once the femur is broken, the structural support for the thigh is lost and all the big thigh muscles contract which cause the bones to move around which of course is extremely painful. Frankly, I've always fervently hoped that this never happens to me.

This guy thought it would be a good idea to go snowmobiling on a frozen lake in the dead of night. That in itself wasn't such a bad idea, but add to that a blood alcohol of .32 and you have a recipe for disaster. In the spring, when the temperatures rise during the day and fall again at night, the ice heaves. He hit an ice heave at about 100 mph ejecting him off the sled and through the air about 20 feet or so. Among his other injuries was a nasty femur fracture with the bone protruding through the skin.

He arrived in full c-spine precautions and his leg immobilized in a Sager splint. A Sager splint is a long metal bar that is topped with a rubber bar that fits snugly in the groin and a strap apparatus that goes around the foot. The splint is then ratcheted out to straighten out the bone which relieves a lot of the pain that is caused by the contracted thigh muscles and the shattered ends of bone moving around. It looks like a medieval torture device but trust me, if it was you, you'd want one!

A femur fracture lookes something like this: (note that is not a Sager splint.)

These are often repaired by putting a big rod up through the shaft of the femur to hold it in place while they heal. Orthopedic surgeons are the only specialty surgery that routinely uses drills, screwdrivers, saws and big mallets during surgery. It's quite something to see. After surgery he had a long hospital stay and then a stint in rehab for physical therapy (he also had a pretty severe closed head injury, helmets can only do so much when you are traveling at 100 mph after all.) Do you suppose he learned anything?

Nah, probably not.

It's change of Shift Time

Change of Shift is up at Emergiblog, please check it out. Once again Kim has done a fabulous job putting it together. Thanks Kim.

It's my First Grand Rounds

It is Grand Rounds time at Shrink Rap. It is my first time submitting for Grand Rounds and I'm very excited to have been chosen.

I really enjoy both Grand Rounds and Change of Shift. I am in awe of the huge amount of thought and planning that goes into hosting them and the talent that is represented there. And I can't believe how much fun it is to participate. When I started this blog I never thought it was going to be read by anyone other than me and my family and friends, now I have new friends all over the blogosphere. Thanks everyone for listening to this nurses voice.

Just how drunk do you have to be?

Drunk man in triage won't tell me why he is here, refuses to talk to anyone but the doctor, and "it better not be some God damn girl either."

It's a small ER and we are not busy so I walk him back to a room even though I am annoyed and tempted to let him have therapeutic wait.

Doctor (man) comes out of the room a few minutes later and he is chuckling and shaking his head. Apparently the man had gotten drunk a few days earlier and decided he wanted to be circumcised so he got out his trusty buck knife and trimmed off his foreskin. By now we are all cringing a bit. The doctor goes on to tell us that, as if that wasn't enough, a couple of nights later while drunk he decided to trim it up a bit and make it a little neater. Now it is terribly infected and he'll probably need surgery.

So we were all wondering, just how drunk DO you have to be to circumcise yourself? He ended up with a couple of surgeries, a suprapubic catheter and a prolonged hospital stay due to the infection and the DT's.