I've mentioned before how much I love our EMS crews. I also admire them greatly for doing a job I could never do. They deal with some incredibly difficult situations and never get the attention and acclaim they deserve. THANKS!
One day the ambulance crew brought in a lady with a complaint of shortness of breath. The back of the ambulance opened and the crew got out wearing TB masks, which back then were made of material that resembled thick cotton batting, not the 'duck bill' masks we use now. I wondered if they thought the patient had TB. About then the smell hit me, it was incredible.
The patient looked 90 but in actuality was only 60 something. She lived in a house back in the hills that had no electricity or running water. A neighbor had called animal control complaining about the huge amount of feral cats that seemed to be coming from her property and when they went to investigate they found her in a house filled with cats, cat urine and cat poo. They medics said there was about a hundred cats in the three room shack and the filth was the worst they had ever seen. She apparently was developmentally disabled and had lived all her life in the shack they found her in, alone after her parents died. No family or friends to check up on her. No medical care ever.
She hadn't wanted to come, but obviously needed medical attention. The sheriff deputy wrote a hold on her and she was brought in. She was quite short of breath, but doing OK on oxygen so we took the medic gurney into the hazmat shower to clean her off. Her legs were grossly swollen from CHF and wrapped in layer after layer of filthy bandages. They were stuck to her with the dried secretions of the oozing ulcers on her lower legs. We soaked them off layer by layer, as we started to remove them, maggots began falling out of the layers by the hundreds. As gross as that was, maggots are superior at cleaning up infection and debriding wounds so when we got to the legs, the ulcers were clean, completely without signs of infection.
Her hair was crawling with lice so we washed it and treated it before putting on a surgical hat to keep it covered. Her clothes were so filthy that they were stuck to her skin in places and also had to be soaked off.
It took us over an hour to get her undressed and clean. She was suffering from scabies, CHF, had a raging UTI and was borderline septic. We admitted her to the ICU where she was placed in a private room with a sticky tape placed on the floor coming out of the room to catch any stray bugs.
This was definitely one of the worst things I had ever seen, and I hadn't even had to go into the house, which one of the medic's described as the fifth level of Dante's hell. I don't know how long it took to decon the ambulance after but I'll always remember that the medic in the back with the patient was being so kind and gentle with the woman, how they helped us clean her up while talking to her in a soft reassuring voice.
If you know someone who works in EMS, take a moment to tell them how great they are. Believe me, they rarely hear it.
Friday, June 29, 2007
Thursday, June 28, 2007
Change of Shift
This weeks edition is at a new site for nurses, Nursing Link, check it out and tell all your friends.
Wednesday, June 27, 2007
Grand Rounds
Grand Rounds is up at Wandering Visitor, it's a very inspiring edition so pull up a lawn chair and a cup of coffee, relax and enjoy.
Tuesday, June 26, 2007
Medication reconciliation
This is why medication reconciliation doesn't work in the ER.
LOL comes in from home. She lives alone with a caregiver that comes three times a week but didn't accompany her to the hospital. She is a very vague historian, has no clue what med's she takes or what pharmacy she gets them from. She gives me her physicians name so I put in a call to his office. Three calls and much time on hold later I finally get in touch with the medical assistant who is finally able to tell me that the patient is not theirs. Close to 45 minutes wasted and still no clue what medications she is on. He last hospital record is from three years ago and she was admitted by the hospitalist then. I could start randomly calling pharmacies but there are 39 of them in the area and that would take hours.
Nice 60ish gentleman comes in with Chest Pain. He knows he takes a blood pressure pill, a water pill and something for his sugar, not the names or the dosages. He gets his med's through the mail from the VA. I don't know about where you work, but I could part the Red Sea easier than I could get that information from the VA.
A 77 year old lady comes in with all her pills (14 different kinds) helpfully arranged in a pill box. It is midnight and her pharmacy and doctors office is closed. It takes over an hour with the identidex system and help from the pharmacist to identify 13 of them. The last one is an alien pill that denies definition and she has no idea what it is for.
I could go on and on. I don't have an hour to spend doing this nonsense. While I am trying to track down the elusive med list, the ambulances keep coming, I need to start IV's, titrate pain meds, do EKG's, start foleys, gastric lavage, restrain and monitor psychotic patients, talk to familys, take admit orders over the phone, arrange to get my patients upstairs and so on and so on. If I am spending hours trying to track down a med list that is one or two or three people that are sitting in the lobby waiting for a bed or a sick patient who's not being taken care of. If I only had one patient I might have the luxury of doing JCAHO's ridiculous tasks, but let's get real - this is the ER where the patients never stop coming.
Nurses need to be at the bedside. Period. If JCAHO insists on this stupidity then they can get the Government to pony up the cash to pay for someone to sit in the ER and do nothing but medication reconciliation forms all day, until then.......JCAHO REFORM NOW!!!!
LOL comes in from home. She lives alone with a caregiver that comes three times a week but didn't accompany her to the hospital. She is a very vague historian, has no clue what med's she takes or what pharmacy she gets them from. She gives me her physicians name so I put in a call to his office. Three calls and much time on hold later I finally get in touch with the medical assistant who is finally able to tell me that the patient is not theirs. Close to 45 minutes wasted and still no clue what medications she is on. He last hospital record is from three years ago and she was admitted by the hospitalist then. I could start randomly calling pharmacies but there are 39 of them in the area and that would take hours.
Nice 60ish gentleman comes in with Chest Pain. He knows he takes a blood pressure pill, a water pill and something for his sugar, not the names or the dosages. He gets his med's through the mail from the VA. I don't know about where you work, but I could part the Red Sea easier than I could get that information from the VA.
A 77 year old lady comes in with all her pills (14 different kinds) helpfully arranged in a pill box. It is midnight and her pharmacy and doctors office is closed. It takes over an hour with the identidex system and help from the pharmacist to identify 13 of them. The last one is an alien pill that denies definition and she has no idea what it is for.
I could go on and on. I don't have an hour to spend doing this nonsense. While I am trying to track down the elusive med list, the ambulances keep coming, I need to start IV's, titrate pain meds, do EKG's, start foleys, gastric lavage, restrain and monitor psychotic patients, talk to familys, take admit orders over the phone, arrange to get my patients upstairs and so on and so on. If I am spending hours trying to track down a med list that is one or two or three people that are sitting in the lobby waiting for a bed or a sick patient who's not being taken care of. If I only had one patient I might have the luxury of doing JCAHO's ridiculous tasks, but let's get real - this is the ER where the patients never stop coming.
Nurses need to be at the bedside. Period. If JCAHO insists on this stupidity then they can get the Government to pony up the cash to pay for someone to sit in the ER and do nothing but medication reconciliation forms all day, until then.......JCAHO REFORM NOW!!!!
Sunday, June 24, 2007
Rules for non-bedside nurses
We are very concerned about the nursing shortage in
America, if the paperwork nurses actually did some nursing, no shortage would exist.
1. Nurses that do not provide direct patient care on a daily basis should not develop policies for nurses that do. (Have you ever noticed how the policies for your nursing practice are written without any input from the people who have to carry out the policies?)
2. Nurses that do not provide direct patient care on a daily basis should not develop forms for nurses that do. (that way a nurse won't have to waste her time putting the VS on the flow sheet and the graphics form and a report sheet etc. etc. etc.)
3. Nurses that do not provide direct patient care on a daily basis should not represent nurses that do in any advertising portraying them as bedside nurses. If you don't do the job, you don't get to claim the glory. ( I don't know about you but I've never seen any of the people who are portrayed as nurses at my hospital or they are all directors and QRM people.)
4. Nurses that do not provide direct patient care on a daily basis should not ever speak for those that do. (It is not OK for QRM to tell admin that the ER nurses should do audits on every patient to see if they meet admission criteria.)
5. Nurses that do not provide direct patient care on a daily basis should not develop staffing guidelines since they have no clue how much work is involved in caring for patients in today's world, including filling out the myriad redundant forms developed by the nurses that do not provide direct patient care on a daily basis. (don't tell us we don't need tech's when you haven't worked at the bedside in 20 years.)
6. Nurses that do not provide direct patient care on a daily basis should not ever have a place on any committee or governmental agency that develop policy or have oversight over nurses that do. (JCAHO etc. needs to have practicing nurses so that someone can tell them how idiotic their policies are and help them actually do some good.)
7. All nursing staff should be required to perform clinical shifts on a regular basis so that they don't lose their skills which may be needed in times of surge capacity and so that they don't forget how hard nurses have to work.
If this sounds a bit bitter, it probably is. Thanks to the non-practicing nurses I now spend more than half my time filling out redundant forms rather than be at the bedside with my patient. And Mouse, you are much too nice. If I got a nasty letter saying I hadn't done an audit I would have to tell them if they had the time to write me a letter, they'd have the time to do the audit themselves. Of course that is probably why I am so popular with the administrative crowd.
America, if the paperwork nurses actually did some nursing, no shortage would exist.
1. Nurses that do not provide direct patient care on a daily basis should not develop policies for nurses that do. (Have you ever noticed how the policies for your nursing practice are written without any input from the people who have to carry out the policies?)
2. Nurses that do not provide direct patient care on a daily basis should not develop forms for nurses that do. (that way a nurse won't have to waste her time putting the VS on the flow sheet and the graphics form and a report sheet etc. etc. etc.)
3. Nurses that do not provide direct patient care on a daily basis should not represent nurses that do in any advertising portraying them as bedside nurses. If you don't do the job, you don't get to claim the glory. ( I don't know about you but I've never seen any of the people who are portrayed as nurses at my hospital or they are all directors and QRM people.)
4. Nurses that do not provide direct patient care on a daily basis should not ever speak for those that do. (It is not OK for QRM to tell admin that the ER nurses should do audits on every patient to see if they meet admission criteria.)
5. Nurses that do not provide direct patient care on a daily basis should not develop staffing guidelines since they have no clue how much work is involved in caring for patients in today's world, including filling out the myriad redundant forms developed by the nurses that do not provide direct patient care on a daily basis. (don't tell us we don't need tech's when you haven't worked at the bedside in 20 years.)
6. Nurses that do not provide direct patient care on a daily basis should not ever have a place on any committee or governmental agency that develop policy or have oversight over nurses that do. (JCAHO etc. needs to have practicing nurses so that someone can tell them how idiotic their policies are and help them actually do some good.)
7. All nursing staff should be required to perform clinical shifts on a regular basis so that they don't lose their skills which may be needed in times of surge capacity and so that they don't forget how hard nurses have to work.
If this sounds a bit bitter, it probably is. Thanks to the non-practicing nurses I now spend more than half my time filling out redundant forms rather than be at the bedside with my patient. And Mouse, you are much too nice. If I got a nasty letter saying I hadn't done an audit I would have to tell them if they had the time to write me a letter, they'd have the time to do the audit themselves. Of course that is probably why I am so popular with the administrative crowd.
Friday, June 22, 2007
Filth
This has always been a pet peeve of mine. Hospitals are filthy. Housekeepers often come from contracted services that provide the lowest amount they can get away with and pay them minimum wage with no benefits. The turnover is stupendous and they have no incentive at all to do a good job.
Oh sure, the center hall is buffed to a glossy finish but the patient rooms aren't wiped down every day, curtains aren't changed, walls not wiped and high dusting not done. All those areas are teaming with bacteria.
ER's are the worst. The gurney and surfaces wiped quickly by the RN in between patients but the rooms are cleaned well only once daily, if that. Pull our the gurney and look at what is under it. No wonder hospital acquired infections are rampant. That should be the first thing looked at when a hospitals infection rates go up, how many housekeepers are there....is one person responsible for covering three units?
I think housekeeping services need to be hospital based, not contracted. Pay them a decent living wage and give them benefits. That way you can attract and retain people that want to work and not the bottom of the barrel. Fire them if they don't want to do the job because there will be people wanting to work for you. Give them proper training on why it is so important to do their jobs well and hold them to a high standard.
It doesn't do the staff any good to wash their hands until they bleed if the hospital itself is filthy.
Oh sure, the center hall is buffed to a glossy finish but the patient rooms aren't wiped down every day, curtains aren't changed, walls not wiped and high dusting not done. All those areas are teaming with bacteria.
ER's are the worst. The gurney and surfaces wiped quickly by the RN in between patients but the rooms are cleaned well only once daily, if that. Pull our the gurney and look at what is under it. No wonder hospital acquired infections are rampant. That should be the first thing looked at when a hospitals infection rates go up, how many housekeepers are there....is one person responsible for covering three units?
I think housekeeping services need to be hospital based, not contracted. Pay them a decent living wage and give them benefits. That way you can attract and retain people that want to work and not the bottom of the barrel. Fire them if they don't want to do the job because there will be people wanting to work for you. Give them proper training on why it is so important to do their jobs well and hold them to a high standard.
It doesn't do the staff any good to wash their hands until they bleed if the hospital itself is filthy.
Wednesday, June 20, 2007
Thank you travel nurses
I want to say thanks to the travel nurses.
I've worked in some places where the staff treats the travel nurses terribly, I've never understood that. After all, it's so much fun to work short staffed so you can afford to be miserable to someone who is coming in to a new place where they don't know anyone to HELP YOU.
And what a difficult job they do. I love to travel and I love the challenge of starting a new job but these wonderful nurses travel to a new place and start a job in a new hospital with only a day or two of orientation and do it beautifully.
Yes, there are a few that aren't very good nurses but for the most of the ones that I have had the pleasure of working with are very sharp, fun, energetic people. I've loved every minute of working with them and hate to see them leave.
Thanks again, travel nurses everywhere!
I've worked in some places where the staff treats the travel nurses terribly, I've never understood that. After all, it's so much fun to work short staffed so you can afford to be miserable to someone who is coming in to a new place where they don't know anyone to HELP YOU.
And what a difficult job they do. I love to travel and I love the challenge of starting a new job but these wonderful nurses travel to a new place and start a job in a new hospital with only a day or two of orientation and do it beautifully.
Yes, there are a few that aren't very good nurses but for the most of the ones that I have had the pleasure of working with are very sharp, fun, energetic people. I've loved every minute of working with them and hate to see them leave.
Thanks again, travel nurses everywhere!
Saturday, June 16, 2007
Nurse Kelly and Scalpel Rock!
Nurse Kelly you rock! I have come late to the N=1 furor. I had some dealings with this person in the past. Initially I read her blog and it started out informative, for instance it brought to my attention the shoddy way the government was treating wounded soldiers and their families and the deplorable conditions at Walter Reed. All too soon it became a whine fest about her lack of readership and lost my attention. Then I and other nursing bloggers were attacked in a post about our blog names being disrespectful to nursing. That made me angry.
Unfortunately someone who is a very articulate writer and could use her talents in a positive way is ruled by some kind of psychosis so that readers turn away from her message and that gift is wasted.
I've said it before and I'll say it again. I don't think I am any better or worse that any member of the health care team. We all bring our own skills and talents to the table. Nurses spend more time with the patient and are invaluable in carrying out the treatment plan and noting subtle change of condition. Most doctors recognize this (thanks Scalpel for posting so eloquently.)
The fact that she responded to nurse Kelly with her name and license number I find to be rather scary, but at least it has been well documented in the blogosphere.
Unfortunately someone who is a very articulate writer and could use her talents in a positive way is ruled by some kind of psychosis so that readers turn away from her message and that gift is wasted.
I've said it before and I'll say it again. I don't think I am any better or worse that any member of the health care team. We all bring our own skills and talents to the table. Nurses spend more time with the patient and are invaluable in carrying out the treatment plan and noting subtle change of condition. Most doctors recognize this (thanks Scalpel for posting so eloquently.)
The fact that she responded to nurse Kelly with her name and license number I find to be rather scary, but at least it has been well documented in the blogosphere.
seizure
She was brought in by EMS after having a full tonic-clonic seizure at work. The seizure lasted about a minute. She was awake and a little befuddled as is often the case in someone that has just had a seizure. No history of seizures so that's a problem. Not that adults don't start having epilepsy, they do, but often new seizures mean something is going wrong in the brain. No medical history, says she has been feeling fine up until today but even today only a mild headache, nothing major.
Off to CT scan she goes. The scan shows a huge mass with multiple 'tentacles'. The mass had started on the right side of her brain but now has penetrated across the midline into the left hemisphere. It's a particularly malignant brain cancer known as Glioblastoma Multiforme, or GBM. The radiologist has never seen any thing like it, keeps asking what kind of symptoms the patient has been having and is disbelieving when we tell him that she has had none before.
We return to the ER where her anxious husband is now waiting. The ER attending is faced with giving them the news. The patient and her husband are bewildered and devastated, but she hasn't been sick? Are you sure? Maybe there is some mistake. How can you go to work normal in the morning and end the day with a death sentence?
Off to CT scan she goes. The scan shows a huge mass with multiple 'tentacles'. The mass had started on the right side of her brain but now has penetrated across the midline into the left hemisphere. It's a particularly malignant brain cancer known as Glioblastoma Multiforme, or GBM. The radiologist has never seen any thing like it, keeps asking what kind of symptoms the patient has been having and is disbelieving when we tell him that she has had none before.
We return to the ER where her anxious husband is now waiting. The ER attending is faced with giving them the news. The patient and her husband are bewildered and devastated, but she hasn't been sick? Are you sure? Maybe there is some mistake. How can you go to work normal in the morning and end the day with a death sentence?
Friday, June 15, 2007
Change of Shift
It's the one-year anniversary of Change of Shift hosted by Mother Jones at Nurse Ratched's, please stop by and celebrate.
Wednesday, June 13, 2007
The sad truth of nursing ratio's
On the face of it, nursing ratio's sound like a good idea - limit the amount of patients a nurse has to take care of and enable them to spend more time at the bedside with their patients. More nursing time at the bedside had been shown in multiple studies to improve patient outcomes, decrease LOS (length of stay), decrease complications of hospitalization such as decubitus ulcers (bedsores,) pneumonia and DVT's (clots in legs.)
The reality is that in a lot of hospitals with marginal finances, to meet the ratio's they have cut all the assistive personnel like phlebotomists, nursing assistants and ward clerks. That means that now the nurses have to draw blood, answer phones, put orders into the computer and so on, all tasks that take the nurse away from patient care. Add to that an ever increasing burden of paperwork and you see the problem.
If your state is considering nursing ratio's, speak up to your state nursing representatives and demand they include language to ensure that assistive personnel are included in the ratio's so that this doesn't happen to you.
The reality is that in a lot of hospitals with marginal finances, to meet the ratio's they have cut all the assistive personnel like phlebotomists, nursing assistants and ward clerks. That means that now the nurses have to draw blood, answer phones, put orders into the computer and so on, all tasks that take the nurse away from patient care. Add to that an ever increasing burden of paperwork and you see the problem.
If your state is considering nursing ratio's, speak up to your state nursing representatives and demand they include language to ensure that assistive personnel are included in the ratio's so that this doesn't happen to you.
Tuesday, June 12, 2007
I'm moving to Texas
Texas has passed legislation to authorize the death penalty for repeat and ongoing sexual offenses involving children.
Grand Rounds
Grand Rounds is up at Revolution Health hosted this week by Doctor Val Jones who has introduced the first FDA approved Grand Rounds in two formulations, Immediate release and Extended Release. Pour yourself a cup of tea (or beverage of choice, pull up a chair and enjoy the read.
Sunday, June 10, 2007
Hygiene issues
When I decided to become a nurse I was a little worried how I would handle smells because I have an over sensitive nose and sometimes bad smells make me gag. Somehow I don't think that gagging in front of a patient is very professional.
Well, I have been a nurse for over 20 years now and I have had very little trouble with smells, oh the occasional whiff of gangrene or a bad GI bleed might get to me a little, but for the most part they are easily ignored in the necessity of caring for the patient.
There is, however, a smell that I can't get used to. A smell that you wouldn't expect to encounter in the progressive nation we live in, the smell of unwashed humanity. A smell we encounter with frightening regularity in the ER.
I'm not talking 'I haven't had a bath in a day or two' or 'I've been working and didn't have time to clean up.' I'm talking people that don't bathe in weeks or months, clothes that are worn until body oil soaks through them and they get a strangely shiny appearance. Hair that hangs in lank, greasy clumps - often infested with vermin. Teeth that are blackened stubs or missing altogether, even in 20-year olds. That dirty, greasy smell often permeated with weeks and weeks worth of cigarette smoke. It's a smell that is thick, coats the back of your nose and throat and often persists in the room for hours after the person has left.
I just don't get it, I shower every day, twice a day if I work or get sweaty outdoors. If I have to skip a day I feel disgusting. How do these people stand it? The thought of being near lice will send me into an itching frenzy for the rest of the day, how can someone have a head crawling with critters and not seem to be aware of them?
And before you say, "well you've never been poor" Oh yes I have. When my first husband left me with two toddlers and no job I washed our clothes in the bathtub on a scrub board that I had as a decoration. Soap is cheap. The homeless shelter has facilities to launder clothes and shower. In this day and age there is no reason to be dirty.
Well, I have been a nurse for over 20 years now and I have had very little trouble with smells, oh the occasional whiff of gangrene or a bad GI bleed might get to me a little, but for the most part they are easily ignored in the necessity of caring for the patient.
There is, however, a smell that I can't get used to. A smell that you wouldn't expect to encounter in the progressive nation we live in, the smell of unwashed humanity. A smell we encounter with frightening regularity in the ER.
I'm not talking 'I haven't had a bath in a day or two' or 'I've been working and didn't have time to clean up.' I'm talking people that don't bathe in weeks or months, clothes that are worn until body oil soaks through them and they get a strangely shiny appearance. Hair that hangs in lank, greasy clumps - often infested with vermin. Teeth that are blackened stubs or missing altogether, even in 20-year olds. That dirty, greasy smell often permeated with weeks and weeks worth of cigarette smoke. It's a smell that is thick, coats the back of your nose and throat and often persists in the room for hours after the person has left.
I just don't get it, I shower every day, twice a day if I work or get sweaty outdoors. If I have to skip a day I feel disgusting. How do these people stand it? The thought of being near lice will send me into an itching frenzy for the rest of the day, how can someone have a head crawling with critters and not seem to be aware of them?
And before you say, "well you've never been poor" Oh yes I have. When my first husband left me with two toddlers and no job I washed our clothes in the bathtub on a scrub board that I had as a decoration. Soap is cheap. The homeless shelter has facilities to launder clothes and shower. In this day and age there is no reason to be dirty.
Saturday, June 9, 2007
Gunshot
The patient was dead on arrival, shot once in the left chest. The resident put in a chest tube and several liters of blood poured out of the chest. The trauma code was called.
The detectives found several thousand dollars cash in the guys pocket.
Wonder what he was doing.
The detectives found several thousand dollars cash in the guys pocket.
Wonder what he was doing.
Friday, June 8, 2007
Not the most brilliant idea
Patient is brought by EMS in full C-spine precautions because he 'blacked out' and crashed his car into a parked car.
Why did he black out? Turns out he was chewing his Fentanyl patch. A Fentanyl patch is applied to the skin and delivers a set amount of pain medicine every hour for three days. Fentanyl is a very potent narcotic and there is a hell of a lot of Fentanyl in one of those patches. The sudden blast of narcotic rendered him unconscious causing him to crash. Barely breathing when EMS arrived he was given Narcan thru his IV which reversed the Fentanyl along with all his narcotics sending him into acute narcotic withdrawal, which is definitely not fun.
I hate to show my not nice side but this idiot could have killed my family member or yours in his ridiculous attempt to get high. After we medically cleared him I took great satisfaction in sending him to jail.
Why did he black out? Turns out he was chewing his Fentanyl patch. A Fentanyl patch is applied to the skin and delivers a set amount of pain medicine every hour for three days. Fentanyl is a very potent narcotic and there is a hell of a lot of Fentanyl in one of those patches. The sudden blast of narcotic rendered him unconscious causing him to crash. Barely breathing when EMS arrived he was given Narcan thru his IV which reversed the Fentanyl along with all his narcotics sending him into acute narcotic withdrawal, which is definitely not fun.
I hate to show my not nice side but this idiot could have killed my family member or yours in his ridiculous attempt to get high. After we medically cleared him I took great satisfaction in sending him to jail.
Thursday, June 7, 2007
Why I HATE Triage, part I
I am triaging a febrile infant, rectal temp 103.2. The baby is in a stained sleeper in a filthy infant seat. Mom says she didn't give Tylenol because she "can't afford it." Mom is carrying a $300 cellphone, has a beeper on the waistband of her designer jeans and is sporting hair extensions. I make a social services referral so they can follow up with Child Protective services but I know that nothing will become of it. (I once suggested to such a mom that instead of buying cigarettes she should but Tylenol for her infant. She complained to administration and I got a written warning in my file.)
It is 2:30 am Saturday and I am triaging a young girl with menstrual cramps. She came to the ER with all her girlfriends and they are giggling and texting on their cell phones in triage. I triage her a category '5' which is the most non-urgent category we have. If we had a category '9' I would have used that.
It is 11 pm and a mother has brought in her child with an earache that he has had for three days. I want to ask, "why now? Shouldn't your kid be in bed?"
I have been in triage for 6 hours and I have triaged 3 frequent fliers with migraines, two dental pains, 4 exacerbation of chronic back pain and one woman with carpal tunnel pain that has passed up three closer ER's because "I like you guys better." Right. Here's a hint, when you have passed up other ER's to come to us we know it is because you have gone to those ER's so much they won't give you narcotics anymore.
I am triaging a 22 year old male with dental pain who's teeth are nothing but black stubs. He reeks of unwashed clothes and cigarettes. His girlfriend has decided that "while I'm here" she'll have a pregnancy test. Oh yuck, that is a visual I sure don't need.
It is 2:30 am Saturday and I am triaging a young girl with menstrual cramps. She came to the ER with all her girlfriends and they are giggling and texting on their cell phones in triage. I triage her a category '5' which is the most non-urgent category we have. If we had a category '9' I would have used that.
It is 11 pm and a mother has brought in her child with an earache that he has had for three days. I want to ask, "why now? Shouldn't your kid be in bed?"
I have been in triage for 6 hours and I have triaged 3 frequent fliers with migraines, two dental pains, 4 exacerbation of chronic back pain and one woman with carpal tunnel pain that has passed up three closer ER's because "I like you guys better." Right. Here's a hint, when you have passed up other ER's to come to us we know it is because you have gone to those ER's so much they won't give you narcotics anymore.
I am triaging a 22 year old male with dental pain who's teeth are nothing but black stubs. He reeks of unwashed clothes and cigarettes. His girlfriend has decided that "while I'm here" she'll have a pregnancy test. Oh yuck, that is a visual I sure don't need.
Wednesday, June 6, 2007
Charcoal
We see a lot of overdoses in the ER. Some are intentional, some are accidental but the one thing they all get is Charcoal.
Activated Charcoal is mixed with water to form a slurry. It's job is to absorb the ingested toxins. The patient either drinks it voluntarily or we put a tube through the nose down into the stomach and pour it down the tube. Sometimes it is mixed with sorbitol which acts as a laxative, speeding up the transit time through the bowel to also purge the toxins from the patients body. It's nasty, gritty stuff which leaves the teeth, tongue and lips black as night.
I've given patients charcoal with sorbitol and had them laying on the stretcher vomiting liquid black emesis off one side and having liquid black diarrhea off the other. It is a remarkably tenacious substance, stains on scrubs never come out and one drop on the bottom of a shoe can cover the entire ER.
I'm going to let you in on a little secret that every ER nurse knows........as soon as you have give the charcoal and sorbitol the whole focus is to get the patient to the ICU before the liquid black diarrhea starts. It's a race against the clock and the loser gets to deal with puddles of liquid black poo. Don't tell the ICU!
Activated Charcoal is mixed with water to form a slurry. It's job is to absorb the ingested toxins. The patient either drinks it voluntarily or we put a tube through the nose down into the stomach and pour it down the tube. Sometimes it is mixed with sorbitol which acts as a laxative, speeding up the transit time through the bowel to also purge the toxins from the patients body. It's nasty, gritty stuff which leaves the teeth, tongue and lips black as night.
I've given patients charcoal with sorbitol and had them laying on the stretcher vomiting liquid black emesis off one side and having liquid black diarrhea off the other. It is a remarkably tenacious substance, stains on scrubs never come out and one drop on the bottom of a shoe can cover the entire ER.
I'm going to let you in on a little secret that every ER nurse knows........as soon as you have give the charcoal and sorbitol the whole focus is to get the patient to the ICU before the liquid black diarrhea starts. It's a race against the clock and the loser gets to deal with puddles of liquid black poo. Don't tell the ICU!
Tuesday, June 5, 2007
More thoughts on MRSA
I have been reading the comments on the previous post about MRSA and isolation. One commenter remarked on how grossed out she was by a patient walking around barefoot. It made me think about people who bring their small children into the ER and let them sit and play on the floor.
Have you ever watched CSI or Forensic files? Have you seen the scenes where they take a black light into a room and shine it around and see how it lights up the places where blood or other biological secretions have been? Well in the ER we have a black light (called a Wood's lamp) that we use to check eyes. You want to be grossed out? Take the Wood's lamp into a room, close the door, turn out the fluorescent lights and turn on the black light. The room will light up like a firecracker and you'll be left to wonder......'I wonder what those spots are on the ceiling?' And wish you could go home for a boiling hot bleach bath.
So for those of you that think that hospitals are gleaming icons of sterility, let me assure you they are not. The number one, most important infection control method is hand washing by caregivers. If you find yourself a patient do not hesitate to ask your care giver if they have washed their hands. With the more and more virulent bacteria we are encountering it can truly mean life or death. And for God's sake, leave you kids at home, you don't want them playing around in the hospital.
If you see a nurse working while wearing a bio hazard suit you will know she went into a dark room with a Woods lamp.
Have you ever watched CSI or Forensic files? Have you seen the scenes where they take a black light into a room and shine it around and see how it lights up the places where blood or other biological secretions have been? Well in the ER we have a black light (called a Wood's lamp) that we use to check eyes. You want to be grossed out? Take the Wood's lamp into a room, close the door, turn out the fluorescent lights and turn on the black light. The room will light up like a firecracker and you'll be left to wonder......'I wonder what those spots are on the ceiling?' And wish you could go home for a boiling hot bleach bath.
So for those of you that think that hospitals are gleaming icons of sterility, let me assure you they are not. The number one, most important infection control method is hand washing by caregivers. If you find yourself a patient do not hesitate to ask your care giver if they have washed their hands. With the more and more virulent bacteria we are encountering it can truly mean life or death. And for God's sake, leave you kids at home, you don't want them playing around in the hospital.
If you see a nurse working while wearing a bio hazard suit you will know she went into a dark room with a Woods lamp.
Monday, June 4, 2007
I'm a Thinking Blogger!
I've been tagged for the thinking blogger award, not once but twice! First by Monkey Girl and today again by Babs RN. Wow! Thanks very much ladies (both of who I admire tremendously BTW.)
Now I'm supposed to tag people that make me think, I have to confess that I am not very good at these things so I'm going to think it over for a day or two until I have a day off and I'll get back to you.
Monkey girl and Babs RN, thanks for the very nice compliments!
Now I'm supposed to tag people that make me think, I have to confess that I am not very good at these things so I'm going to think it over for a day or two until I have a day off and I'll get back to you.
Monkey girl and Babs RN, thanks for the very nice compliments!
Thoughts on MRSA
The ER serves a large population of people that have a history of MRSA, most of them the community acquired strain which causes the epidemic of abscesses we are currently dealing with.
When you are in the hospital and you are known to have a drug resistant organism you are put on isolation. That means you are expected to stay in your room, except when leaving to go to a diagnostic test, and people entering the room wear a protective gown and gloves which are removed when they leave the room. This is to keep the organism being spread from room to room, patient to patient, on our hands and clothing.
The ER is a little different. These people come in and sit in the lobby with everyone else, the use the public bathroom. They sit in the triage room (which is never cleaned as far as I can tell) in the same chair that everyone else uses. Then when they come back to a room they get put on isolation. I dunno, to me that just makes no sense at all.
I don't know how it is at other hospitals but anywhere I have ever worked housekeeping is pretty poor. The public has an idea of hospitals as gleaming clean but that is just not the case. The truth is, in an effort to make as much money as possible, most hospitals hire the fewest housekeepers possible and pay them minimum wage with no benefits. What you get in return is a revolving door of people who are working there because they can't get another job at the moment and move on as soon as possible. While they are there there is no real incentive to do a good job. They are overwhelmed by the amount of cleaning they are supposed to do daily, there is no way that one person could do it, so they just do what they can, and it is never enough. If you look closely, you'll see grime in the corners, dust on the ceiling vents, the tops of the furniture wiped, but the sides and bottoms grimy. Floor waxing, which should be done quarterly, done once a year or less. Have you ever seen the chairs in the waiting room wiped down? I didn't think so.
But I'll bet the executive offices are clean.
When you are in the hospital and you are known to have a drug resistant organism you are put on isolation. That means you are expected to stay in your room, except when leaving to go to a diagnostic test, and people entering the room wear a protective gown and gloves which are removed when they leave the room. This is to keep the organism being spread from room to room, patient to patient, on our hands and clothing.
The ER is a little different. These people come in and sit in the lobby with everyone else, the use the public bathroom. They sit in the triage room (which is never cleaned as far as I can tell) in the same chair that everyone else uses. Then when they come back to a room they get put on isolation. I dunno, to me that just makes no sense at all.
I don't know how it is at other hospitals but anywhere I have ever worked housekeeping is pretty poor. The public has an idea of hospitals as gleaming clean but that is just not the case. The truth is, in an effort to make as much money as possible, most hospitals hire the fewest housekeepers possible and pay them minimum wage with no benefits. What you get in return is a revolving door of people who are working there because they can't get another job at the moment and move on as soon as possible. While they are there there is no real incentive to do a good job. They are overwhelmed by the amount of cleaning they are supposed to do daily, there is no way that one person could do it, so they just do what they can, and it is never enough. If you look closely, you'll see grime in the corners, dust on the ceiling vents, the tops of the furniture wiped, but the sides and bottoms grimy. Floor waxing, which should be done quarterly, done once a year or less. Have you ever seen the chairs in the waiting room wiped down? I didn't think so.
But I'll bet the executive offices are clean.
Sunday, June 3, 2007
What is wrong with this country
You have to wonder what is wrong with the society you live in when you are taking care of a 20 year old with chronic back pain who is on METHADONE. What the hell? Barring a history of some sort of severe trauma or uncorrected congenital deformity how in the heck can a TWENTY year old have such bad back pain that they need to be taking methadone? Oh, and be on permanent disability.
Who is prescribing this? I'm sorry, but this is criminal. This is where America is going, right down the tubes. Surrounded by a people who want to live every day in a drugged out haze. Oh, and they are all around driving their cars - happy thought, huh?
So why was this patient in the ER? Well their pain doctor gives them enough meds for a month and they were out. A week early. And in acute narcotic withdrawal. Sad. I guess we can look forward to repeat visits for the rest of the month until it is time to get the methadone filled.
Almost everyone who comes to my ER is taking Vicodin, Soma, Baclofen, Klonopin and Xanax. All these meds are very sedating. All these people drove themselves to the ER. That is something I think about a lot since my kids started to drive.
Who is prescribing this? I'm sorry, but this is criminal. This is where America is going, right down the tubes. Surrounded by a people who want to live every day in a drugged out haze. Oh, and they are all around driving their cars - happy thought, huh?
So why was this patient in the ER? Well their pain doctor gives them enough meds for a month and they were out. A week early. And in acute narcotic withdrawal. Sad. I guess we can look forward to repeat visits for the rest of the month until it is time to get the methadone filled.
Almost everyone who comes to my ER is taking Vicodin, Soma, Baclofen, Klonopin and Xanax. All these meds are very sedating. All these people drove themselves to the ER. That is something I think about a lot since my kids started to drive.
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