A Weighty Issue

In the years I have been a nurse I have seen obesity skyrocket. When I first started you rarely got patients over three hundred pounds and now they are a dime a dozen. We are seeing so many 500+ pounders that we have had to buy a special gurney and the ambulance companies have had to add special equipment. Upstairs on the floors they have had to purchase special commodes, wheelchairs, beds and lifts.

Some of these unfortunate people are so large that they are unable to stand, their legs will not support them. They have to lay in bed, day after day. Each breath a struggle to lift their massive chests to allow their lungs to expand. Their hearts failing trying to handle the insurmountable task of pumping blood throughout their grossly enlarged body.

I only have on question. If you can't get to the refrigerator on your own, who is bringing you food? And why?

Comfort Care and Mass Casualty Triage

I was reading a post on From Medskool about the Dr. Anna Pou case, the doctor accused of euthanizing patients at a New Orleans Hospital during hurricane Katrina and the aftermath. Along with nurses she was accused of injecting four patients with two drugs, Morphine and Versed and causing their death.

“When you use both of them together, it becomes a lethal cocktail and guarantees they’re going to die,” the attorney general, Charles Foti, announced."

That is patently untrue. Morphine and Versed are used in combination all the time to treat pain and anxiety. You would think that people would do some research before spouting off things they know little about wouldn't you?

A handful of doctors and nurses made the decision to stay in the hospital with the patients. Tuesday found them stranded in a hospital with no electricity or running water. It was horribly hot, the levee's had broken and the water was rising. An occasional boat or helicopter came to evacuate patients. To take a patient to rescue meant carrying them down seven flights of stairs and then up to the top of a parking garage, it was brutal for the staff and several patients were unable to survive the trip. By Thursday patients were dying of dehydration, suffering in the heat. No one was coming to evacuate them and still the doctors and nurses were there. They decided to try to evacuate the remaining patients themselves. That is when Dr Pou and two nurses, Cheri Landry and Lori Budo are accused of administering lethal doses of those drugs to four patients.

Those doctors and nurses could have left like all the doctors and nurses that weren't there. Nobody faulted the ones that left. Instead they stayed with their patients in the sweltering heat, the dark, isolated by ten feet of filthy water with dead bodies watching the sick patients under their care suffer and die one by one. They were abandoned there, cut off from all communication and had no idea when or if help would ever come. And still they stayed. They were abandoned by the city and the federal government, LEFT TO DIE.

The truth is, comfort care is administered in hospitals around the world. Patients with no hope of survival are removed from life support and given pain and anti-anxiety medicine to prevent gasping for air and suffering as they die. It is an accepted practice. It is accepted that those medications may hasten the death that is going to happen any way but it is more humane to keep the patient from suffering as they die.

If a mass casualty incident were to occur, we will revert to battlefield triage. The injured will be divided into three categories, black, red and green. Black means dead or dying. Those designated as black will be placed aside to die so as not to use up precious resources when they have no hope of survival. Red means critical with chance of survival, they will be treated first. Green is walking wounded. They will be left to make their own way to treatment areas. That means some of the wounded will be consciously left to die. Will we be accused of murder after the event is over by people who weren't there and have no idea what was involved? And if a mortally wounded patient is going to be left to die, wouldn't it be kinder to administer a large dose of pain killers or sedatives if available on the off chance they have enough awareness to know that they are dying and in pain?

Thoughts about constipation

If you are able bodied and come to the ER because you are constipated do not expect that I am going to give you an enema. The are hundreds of laxatives and even Fleet's enemas available at every grocery store and pharmacy in America. Why on earth would someone not try some of those readily available remedies? If you come to the ER having not tried any of those things and the doctor orders an enema you are going to be sent into the bathroom with an enema bucket to take care of business while the nurses take care of the sick people.

Do not come to the ER with constipation and be discharged with a gallon of Golytely only to return the following day because you have diarrhea.

If you take Vicodin all the time for the love of God, take a couple tablespoons of Milk of Magnesia every night.

Not moving your bowels in one day is not an emergency. Once again, take a couple tablespoons of Milk of Magnesia.

Arrest Induced Chest Pain

Arrested for Methamphetamine manufacture, develops chest pain while being booked. $600 ambulance ride, negative cardiac workup but pain goes away with Nitro and he has risk factors. $5000 ER bill. That ER has no cardiologist so he gets a $6500 helicopter ride to a tertiary center where he has $10000 negative heart cath. That is a $22000 get out of jail free card. And the kicker is that the county will end up footing the bill. Priceless.

Drug seeking again

I was reading a post at Scalpel or Sword today that made me think of some examples of drug seekers that are pretty funny in a twisted sort of way. I don't know if these people are too stupid to know how stupid they are or how they thought they would possibly get away with these acts but they do try.

The first of our culprits took a Vicodin prescription written for 10 pills and added a '0' making it 100 pills. They might have gotten away with it except our narcotic prescriptions have quantity checkboxes and the 1 - 24 box was checked. Oh yeah, the added zero was in a different color pen. And the patient came back to the ER to ask why we cancelled the prescription. It made it much easier for the police to find them.

The next one added a '1' to the '0' refills making it a ten. The astute pharmacist thought it was odd that the ER would write for ten refills on a vicodin prescription and called us. They were asked to stall the patient while we notified the police.

I have seen more than one person poke their finger for a couple of drops of blood to put in their urine sample to fool us into believing they had a kidney stone. Real kidney stones are excruciatingly painful and often require large doses of narcotics and we are happy to give them as the patient is suffering so.

We are very rigid about requiring a ride to be present prior to administration of narcotics for patients that are not emergently ill, like back pain, migraines etc. I have had a patient go out in front of the hospital and convince someone to come in and say they were the driver. I have had a patient sneak out the back door after receiving ativan and back into another car. It always looks good to the incoming patients and families to have an arrest taking place in the parking lot.

Our regulars know the rule about the rides so they will sign in to be seen and neglect to mention that the driver is also signed in as a patient.

I've been told by patients in the lobby that they heard a patient come out and use the courtesy phone to call a buddy to tell them "dude, I scored 20 Vicodin!"

I've been called by pharmacies to say "We just filled a prescription for 180 Vicodin for this patient yesterday, do you want us to fill yours today?" That would be no, cancel that please. And then you have to wonder, with approximately 50 pharmacies in a 20 mile radius, they would go to the same one.

Some people would think, what does it matter, they aren't hurting anyone but themselves. That is not true. First of all, they are taking up an ER room when sicker people are waiting and ambulances are getting diverted. Then, they drive around under the influence and kill and injure innocent people. Most of them don't work and are on welfare or disability for some made up medical problem and their support is coming out of your pockets. They run up billions of dollars of medical cost yearly which also comes out of your pockets and causes our insurance and out of pocket costs to rise continuously.

so isn't that a happy thought, I am working 60 or more hours a week to scrape by so that I can support their drug habit. Yippee.

Grand Rounds

Grand rounds is posted at Rickety Contrivances of doing good. The theme this week is narrative medicine. Please take the time to check it out and leave a comment congratulating Susan on a great job. I am in awe of the huge amount of thought, talent and effort that goes into putting together a blog carnival. A lot of great blog talent can be found there and you can count on a great read.

Nurses bill of rights

A commenter on a recent post suggested I write a 'Nurses Bill of Rights' and I think it is a great idea but I don't know where to begin, how about some suggestions.

SICK!

"Hey" the security guard was standing at the counter where I was charting. "There's a lady outside who needs some help getting her husband out of the car."

I got a wheelchair and followed him out front to the ambulance bay where a woman was standing next to a minivan literally wringing her hands and crying.

I went around to the passenger side of the vehicle. It has long been my belief that the people most in need of an ambulance usually come by private car and one look inside told me that this was one of those guys.

"Go inside and grab the first nurse you see and tell them to come out here with a gurney and some help." While he was inside I asked the woman how long her husband had been like this. 'This' was obtunded. A good nurse can tell with one look when someone is really sick and 'this' was it. According to her, he had been ill yesterday with flu-like symptoms and was okay when he went to bed last night. He had awoken her this morning thrashing around in delirium.

We got him out of the car and onto the gurney. Truth be told, we manhandled him out of the car, he was dead weight. There is no good way to get someone out of the car that can't help you. I still can't imagine how his wife got him in the car. Through the pneumatic door and into the 'crash' room, yelling for a doctor, respiratory and xray. The patient was hot to the touch and moaning incomprehensibly. As we cut away his clothes we saw the petechial lesions on his arms and legs. Any good critical care nurse worth their salt will be able to identify Meningococcemia, and here it was right in front of us.

Initial BP was 69 systolic, HR was 167. Lines were started and fluid boluses given. The patient was quickly intubated and put on the ventilator to protect his airway. BP remained low so powerful vasopressors were started and the shock team was called. Two doctors and three nurses were running non-stop hanging drips, inserting lines, monitoring vitals in an intense effort to save his life.

Before long he was whisked off to the ICU, slightly more stable with a blood pressure of 88 systolic on high dose Levophed. I found out later that he did survive but had a 4 month long ICU stay and lost all of his toes. Surviving this deadly illness does not mean returning to your previous level of function or quality of life.

As deadly as this disease is, employee health didn't want to treat the staff, stating the disease is only transmitted with close personal contact. Maybe so, but my peace of mind is worth the price of that one Cipro tab. Sheesh.

I got a pretty good laugh out of this, brings a whole new dimension to lost condom stories.

Those of us in Emergency Medicine aren't the only ones that have to deal with idiots as seen in this post.

Violence isn't only in the ER

The ER is not the only place where violence is a growing problem. I'll bet plenty of medics have a story to tell about how much fun it is to be confined in the back of an ambulance with some one who is going berserk.

Tagged

I was tagged by Not Nurse Ratched for a meme, but to be honest I was barely able to think of 8 the first time so I'm going to decline this time. I've come to the sad realization that I live a very boring life.

More on ER violence

ER violence is a very real threat.

Several years ago I was working in a large urban hospital in the middle of gangland. We saw penetrating trauma almost daily. The ER was built within 5 years of when I started there and was very poorly designed. For example, the front wall was built out of metal panels and large sheets of glass. The staff pointed out that while attractive, it would do nothing to stop a vehicle from driving into the waiting room. Our concerns were pooh-poohed, administration pointed out that we had security stationed in the waiting room 24/7. Well, um, yeah. Most of them were older than the hills and no match for a speeding car. You know how sometimes pointing out problems is like shouting down a well? Yeah. This was one of those times. Until the car came crashing through the wall one day. A little old man who stepped on the gas instead of the brake and drove right into the lobby. Fortunately it was early in the morning and no one was sitting in that area. You can bet administration put some concrete pylons in front of the ER after that. Thank God no one was hurt or killed.

The waiting room was divided into several sections and one was a room out of the direct view of the staff and security. The staff pointed out that fact and that the seclusion wasn't safe. Once again we were pooh-poohed until a girl got assaulted back there late one night and then you better believe they knocked that wall down so there were no hidden corners.

The ER had a lot of rooms. a lot. Also had a dedicated pediatric ER. Two patient bathrooms for the whole place. The ER had a lot of staff, when fully staffed we had 18 nurses, 5 techs, two secretaries, three housekeepers and two security guards. We had a full-time social worker and two or three volunteers. For medical staff there was three attendings and 9 residents as well as all the consulting services. On a busy night, it was possible to have close to 100 staff in the ER and there was ONE STAFF RESTROOM. For the love of God, who approved that plan anyway?

Anyway, you get the idea. The people running the place were a few bricks shy of a full load.

One night I was assaulted in triage by a patient who reached over my desk, grabbed me by the neck and choked and started punching me. The security guard, who was across a little hall, was looking out the window and didn't notice what was going on right away. Then he was too old to be much help. Fortunately, there were several city police right out front and notice the commotion and pulled the guy off me. I suffered a black eye, abrasions to my face and neck and a broken pair of glasses.

A big to-do ensued. The police asked me if I wanted to press charges. I said "you are damn tooting I do." Or something like that anyway. The nursing supervisor who had shown up by now disapproved. He exact words were, "We don't want to do that to a customer." I'm no shy retiring flower. I told her in no uncertain words that in my opinion she should be a little more concerned that a hospital employee had just been attacked on the job and injured and how were they going to go about replacing my glasses which were destroyed and I couldn't see to drive home, which I was going to do as soon as my assailants sorry ass was in jail.

She was not pleased.

The guy was prosecuted, they got off duty police in the department from 7 pm to 7 am but not too long after that another nurse was assaulted by a crackhead mother of her pediatric patient. At that point, I decided to move on.

How many medical professionals have been assaulted while at work and pressured by administration to keep quiet about it? How many people, dependent on their wages take the path of least resistance?

Emergency room violence is a growing concern for nurses.

When you know you are doing something right.

When there are four hospitals in your city but the medics come to yours when they are ill.

When you are taking care of a cancer patient who comes in with agonizing pain and you have medicated them and they are peacefully sleeping, pain free for the first time in a long while.

When the family of the woman from the MVC that was brain dead but you assisted the family in making the decision to donate her organs sends a dozen roses to thank you for making the hardest day of their life a little easier.

When you make the terrified parents of the two year old that just had his second febrile seizure feel a little better.

When you team saves the life of the pizza delivery guy who was caught in stray gang gunfire and shot in the chest. He is one of the few that truly was 'minding his own business.'

When your testimony helps get a horribly abused little child taken away from his monster mother forever.

When your careful evidence collection assists in convicting a rapist.

When you are there to support a family in making end of life decisions for their loved one.

Change of Shift: Volume 2, Number 5

It's Change of Shift time at Nurse Ratched's place, the theme is Round Up Time. Mother Jones always has the neatest vintage pictures on her site, I could just look at them all day, makes me think of a kinder gentler time in America. Anyway, pour yourself a cup of coffee and stop by and give it a read.

He was a gentleman

I was taking care of a man who was 40 but looked at least twenty-years older. He was tattoo'd from head to toe, including the obligatory prison tattoo's 'LOVE' and 'HATE' on his fingers. his arms bore the scars of decades of drug abuse, teeth were missing and his belly distended with the accumulated fluid of liver failure.

I gathered my IV supplies and headed into the room. Introducing myself, I explained what I was going to do, to which the patient replied, "you be careful ma'am, I have Hepatitis C."

I've been kicked, punched, shoved, spit on. I've had patients pinch me, crush my fingers and one even tried to choke me (he had Alzheimer's.) But nothing has surprised me as much as this concern for my well being from this unexpected source. I was ashamed and humbled because I had failed to see the humanity beneath the man's exterior. It was a real eye opener for me.

I came to know this man well, taking care of him in our ER for years as the ravages of liver failure stole away his life. He was never anything but kind, patient and uncomplaining of how his life turned out.

Rest in peace Robert*, I hope you are pain free and at peace.


*not his real name

When Bloggers Find Love

I'm perusing my blogroll this morning in an attempt to put off the housework and much to my surprise I find this and this.

How neat that two of my favorite bloggers have met, become best friends and then fallen in love. Congrats to Babs and Ambulance Driver.

A Funny Take on Being on Call

Very funny post even though I suspect the part about sending the patient to the ER is all too true. Welcome Dr. White Coat Rants.

ERnursey's son has been deployed. Needless to say, this has not been the best day of my life. Despite what you think of the war in Iraq, please join me in praying for and supporting the brave men and women who are serving there. Think of what you can do to support them and their families and then GET OUT THERE AND DO IT!!!!

Now excuse me while I go and have a good cry.

Grand Rounds

Medsource is presenting Grand Rounds this week, go check it out!

Obtaining Follow up

23 of the patients we saw today had been in the ER in the last 72 hours. Only two of those had been invited back. So what is the problem? Some of them, as discussed in previous posts, are drug seeking but a growing number of them are indigent med-i-cal patients who can't get into a primary physician because the only ones in town won't accept new patients and one of those is losing doctors at an alarming rate so they aren't able to see the patients they already have.

What is the answer? I'm not sure. I have mixed feelings about universal health care. I think the idea of available health care for everyone is a great idea. However it will be a government program and they will screw it up like everything else they get a hand in. I do know that the ER's around the country cannot continue to be forced to absorb the care of all the people in America that don't have private insurance, the ER is not a CLINIC it is for EMERGENCIES.

The Dog Ate my Homework

Heard from different patients today.

"I have severe disk disease and am disabled. I am on vacation and forgot my Methadone."

"My Vicodin prescription blew out of the truck window."

"My ex-girlfriend stole my oxycontin."

"My doctor can't see me until the first (which is two weeks away) so he told me to come to th ER to get my refills."

Patient number 1 - let's have your doctors name and we will call him.
Patient number 2 - Please, do we look that stupid?
Patient number 3 - Jeez, that is too bad. Here is the number of the police, narcotic theft is a crime. However, you'll have to get your meds from your doctor. (Once again, do we look that stupid?)
Patient number 4 - let's just call your doc, 'Oh, you fired him from your practice for doctor shopping? Surprise!'

Which one do you think is telling the truth?

Patient number 1 is a 40ish man with no medical history that comes in from his job at a construction site where he suffered a sudden onset of right flank pain. Driven in by a co-worker he is barely able to walk in, hunched over, pale, sweaty, diaphoretic, writhing on the gurney, tachycardic and hypertensive. Shortly after getting to triage he starts vomiting. During triage he seems apologetic when he rates his pain a "7 or 8."

Patient number 2 is a twenty something who is brought in from the parking lot in a wheelchair by a friend, they are laughing and talking on their cell-phones when you bring him in for triage. Chief complaint is a twisted ankle. Despite apparently being able to walk to the car at home he is now unable to walk and has to be brought into triage in a wheelchair. In triage his skin is pink, warm and dry and vitals are normal. He rates his pain a "12."

Patient number 1 is given Toradol and Compazine IV and has complete relief of his pain. He is diagnosed with a small, non-obstructing kidney stone. Discharged home with prescriptions for Motrin, Vicodin and Flomax as well as a urine strainer.

Patient number 2 is diagnosed with muscle strain. He is offered an stirrup splint and a prescription for Motrin. He is unhappy and demands a pain shot, crutches, work note and a prescription for Vicodin. He is told no at which point he jumps off the gurney and stomps out of the ER in a huff, screaming "I'm never coming back to this motherfucking place." Another miracle cure, courtesy of emergency medicine.

This is the kind of thing that clogs up ER's all over our country. America is filled with people that contribute nothing to society but come equipped with a massive sense of entitlement, they want what they want, when they want it, when they want it. Told no, they became belligerent and assualtive, spewing threats toward they staff. Fearing patient complaints or confrontation, more than one practitioner has taken the path of least resistance. Hospital administration, driven by their wish for high patient satisfaction scores, fails to allow MD's to practice medicine and join JCAHO in forcing us to be legalized drug pushers rather than medical practitioners.

Someday, when there is an epidemic or surge of casualties from a natural disaster or terrorist attack the ER won't be able to care for those victims because we will be full of patients with 'chronic pain' who are seeking drugs.

This is the skin of a meth user. ER's across the nation are seeing an epidemic of abscesses.

What started in the drug population is now being seen in everyone, including babies. It is a virulent form of 'Staph' that lives on everyone called MRSA. The infected meth user has this bacteria on their skin and they pass it around by touching every day objects, like shopping carts.











This is Meth mouth. Meth dries out the saliva that washes bacteria off the teeth. That, along with poor diet and craving sugary sodas, cause the teeth to weaken, rot and crumble.

How'd ya like to kiss this?

These are faces of meth users. Pretty hot, huh.


In addition to the obvious physical symptoms, meth users develop muscle twitching, lip smacking, head jerking movements that often never go away, even if they kick the habit. Users also suffer from psychotic symptoms such as paranoia, hallucinations, anxiety, agitation and delirium. These psychotic symptoms may also persist after the user stops.

The manufacture of meth uses a host of toxic chemicals like Drano, muriatic acid and red phosphorus. These poisons are dumped illegally by the 'cooks' finding their way into ground water and soil. Unwitting people move into houses where meth has been manufactured to find that they develop chronic illnesses from the poisons in the walls and carpeting. Meth labs occasionally explode putting innocent people at risk as well as endangering firefighters and law enforcement from poisonous fumes. There are often children living in the residence where meth labs are in operation, no one knows what the long term effects of exposure to the toxic fumes will be.

I'm all for letting the drug users kill themselves off, but there are too many innocent victims of this drug. In addition, meth use contributes to billions of dollars of unreimbursed medical costs every year. I estimate that up to 50% of the patients in my ER are meth users being seen for Abscesses, dental pain, chronic pain, narcotic seeking, chest pain, brain bleeds, septicemia, endocarditis, agitated delirium and so on and so on. Most of them are on welfare and medicaid so your tax dollars are supporting their habit and paying the high medical costs of their abuse.

Steps have been made to curb the manufacture of methamphetamine, like taking sudafed off the shelf and curtailing the amount that can be purchased but it is too little. Methamphetamine is more of a threat to America than terrorism and should be treated as such. Please join me in writing to your government representatives to demand harsher action against Methamphetamine manufacture, distribution and use.

Meteor Showers

Um, OK. Is it me or has the meteor shower made everyone completely nuts?

Family Encounters Part 2 - or 'Don't call an ER nurse names!"

Ring, Ring, Ring

"Hello, this is Random ER, my name is ERnursey, how may I help you?"

"I'm looking for my baby daddy, Shemar Washington" (false name to protect the guilty)

"Um......hang on a minute."

The baby daddy in question already had a baby momma at his bedside, weeping and wailing because her baby daddy had been shot in the leg by the infamous "Sum Dood." He had been a complete asshole since he arrived and she had been at the nurses desk every 30 seconds wanting food for her man despite them being told a hundred times he might go to surgery and couldn't have anything.

I went to the bedside to ask if I could give information to the caller. Before I could even open my mouth, the patient looked up at me and said "about time bitch." I didn't even answer, turned and left. I went back to the phone: "He's in bed three and he says he wants you to come down as soon as you can."

After hanging up, I gave an evil chuckle. I figured the imminent cat fight would be poetic justice.

Family encounters Part 1

Ring, Ring, Ring

"Hello, this is random ER, my name is ERnursey. How may I help you?"

"I'm looking for my family member, he was shot."

"What's his name sir?"

"Dewayne"

"What's his last name sir?"

"Well it starts with an S"

Right. Close family huh? Do these people really think we are that stupid? Or are they too stupid to know that they are stupid.

The Most Annoying Patient of the Day

coming from room 31 the volume was deafening.

"I can't breathe, I can't breathe, I can't breathe, I can't breathe, I can't breathe, I can't breathe, I can't breathe, I can't breathe, I can't breathe, I can't breathe, I can't breathe........" and on and on without any apparent pause for breath. The sheer volume told us the patient was able to breathe A-OK.

Put 2 hours off that with a background of constantly ringing phones, EMS radios, Call lights and overhead pages and you will have a pretty good idea of why I just washed down four Advil with a big glass of Merlot.

Terrible Tuesday

I. Am. So. Tired. I. Just. Want. To. Lay. Down. And. Die.

WHY OH WHY DID I SIGN UP FOR AN OVERTIME DAY TOMORROW?!!!!!!!


Damn Visa Bill.

Black Monday

It was so busy today and the patients so nutty I had to look twice at the atomic clock to see if it was full moon, it wasn't. One of the first patients of the day showed up in a parka (it's 97 degrees outside here) and to said parka she had glued multiple layer of aluminum foil (to block the transmitters.) Needless to say, it was all downhill from there.

The next psych patient was a 16 year-old suicidal male. When the police finally tracked down the mother it was sadly apparent that she was the problem. It's a well known fact in the ER that 99% of kids that have psych problems it is the parent that is the problem, the kid never had a chance.

Then we had a run of bowel problems. What is it with people and their bowels? Don't you have anything to focus on? Hasn't anyone ever heard of a drug store? Why on earth would someone come to the ER because they are constipated? I can understand it in the case of a patient who is physically unable to care for themselves, but in an otherwise healthy, able bodied adult? Milk of magnesia people, fleets enema (which is available at the grocery store for crying out loud.)

And in the midst of all the bedlam......the icing on the cake. A pregnant woman, two weeks overdue who thought it would be a good idea to go on the road with her long-haul truck driver baby daddy, arrived in the 18-wheeler in our parking lot crowning. Yippee (not.) Have I mentioned how ER nurses hate childbirth? Try to assist a resident delivering a baby in the back of a semi!

Then at the finish of my day, I finally got a minute to empty my seriously over-filled bladder and when I pulled my scrub pants up I flipped the charge nurse phone into the toilet. Great.

Well the good thing is.....tomorrow is Tuesday and Monday only comes once a week.

Here is a list of some ER truisms I came across today, I especially like number 7.

ER Ward Clerks

I ran across a post over at Gruntdoc when I was perusing his archives. You can find it here. I just want to say AMEN! A good ward clerk makes the ER run like a well oiled machine. They have to be like an octopus, juggling several tasks at the same time all the while answering the constantly ringing phones. I've filled in their job for short periods here and there and I have to say if I was forced to do it for more than an hour or two, someone would die. They are the unsung hero's of the ER, underpaid and under-appreciated.

When you go to work today, make sure you tell your Clerk(s) how much you appreciate the job they do.

And thanks Gruntdoc, for noticing this first.

Search Engine Topics Part 1

In perusing my site meter, I have noticed an alarming amount of searches for 'chewing Fentanyl patches.'

If you are contemplating chewing a Fentanyl patch in an effort to get high, then you are a dumb ass!

If you are contemplating chewing a Fentanyl patch in an effort to assist Darwin in proving his theory then by all means go ahead.

ER Privacy Issues

Let's face it, ER's are crowded and noisy. Despite our best attempts to maintain a patients privacy, when the next patient is six feet away with only a thin curtain between them, it is hard not to over hear what is going on next to you.

One night we had an elderly gentleman in curtain area 1 and next to him a prim, middle aged lady. The PA was trying to explain to the man what his diagnosis was but his efforts were being hampered by the fact that the man was very hard of hearing. The problem was something of a personal nature so the PA was trying to be discreet.

PA: Sir, you have pubic lice
PT: What's that you say?

PA: I said you have pubic lice.
PT: What?

PA: You've got lice down there
PT: Can't hear you son, you have to speak up

PA: I SAID YOU HAVE BUGS DOWN THERE
PT: Oh.

Of course we all overheard the conversation, including the prim lady in the next cubicle, who was red as a beet by now. The ER staff, dignified until the end, were draped across the counters shaking with silent laughter until tears ran down our faces.

Most of the time privacy in the ER is an illusion maintained by patients pretending they don't see or hear what is going on around them. Sometimes it is impossible to pretend.

Pain Scale

Here is an excellent pain scale. Thanks Monkey Girl and Scalpel.

Getting a patient admited

Why is it, I can tell during triage with 90 percent accuracy if a patient is going to need admission but you can't prove it to the admitting service without three rounds of lab work, a CT and an MRI?
And then, they will try to shuffle it off onto another service.

For instance: A patient is brought in from a MVC. The mechanism meets trauma criteria but after exam, xrays and CT the only injury is a femur fracture. Hospital policy states that all traumas are admitted to surgery for 24 hours. Seems pretty clear cut to me right? Wrong. Her is a condensed version of the next 3 hours. Surgery comes to the trauma and says "admit the patient to ortho." So the ER resident calls ortho. Time passes before the ortho resident has time to come to the ER and, when he hears that the patient is a trauma, refuses to admit. Now we place several fruitless calls to surgery before the resident finally comes down. An argument ensues because the resident clearly doesn't want to be bothered. The ER attending finally has to call the surgery attending and the surgical intern finally admits the patient.

Another day, another patient. This one has a hip fracture from a ground-level fall. Ortho comes and examines the patient and says "have medicine admit." The medicine resident, when finally reached, says no. The patient has no real medical needs, is only on a BP med and some arthritis pills so could easily be admitted to ortho. You get the idea.

What is the solution? Got any ideas.

Exactly! I'm sick of trying to explain my problem to someone who doesn't speak english or understand it for that matter. Let's all band together and refuse to do business with any company that outsources any of it's services. So far I have fired my satellite company, my credit card and refuse to buy anything from SONY. I'm sure many more will follow.

Thanks Monkeygirl

The LawDog Files: This is exactly what I'm talking about ...

Leave it to our government to screw this up.

It's Change of Shift time again and this weeks hostess, Kim at Emergiblog, has developed a new banner for the second year of this nursing blog carnival.

We could hear screaming and wailing from the ambulance bay before the ambulance door had opened. That sounds alarming but this was our newest frequent flier giving an academy award performance.

According to the computer, this was the fourth visit this month for the same complaint for which she had been worked up ad infinitum. Apparently, reviewing her last visit, Dilaudid was the drug of choice and she would usually make a miraculous recovery and demand to be discharged. Her husband was rude and threatening to the staff if we didn't medicate her within minutes of her arrival.

Reviewing her records I noticed they lived in a town 45 minutes away. The town had a very good hospital in it. I found it odd that they would travel 45 minutes away when there was a hospital there and I said so. "Oh, they don't know they are doing there, my doctor told me to come here." Oh really........I made an off the record call to the charge nurse at the other place and he told me that the patient had been a very frequent flier there. She had been fired by every PMD in town, even Dr. Feelgood. They had put her on a contract that if she came to their ER she would get no narcotics so she stopped coming and as far as they knew, she had been going to another ER south of them.

I let the Dr. know about this, he asked me to get the patients ER records from the other hospital so I went into the room and asked for her to sign a records release form. Keep in mind that she has been screaming and wailing throughout all of this supposedly in excruciating pain. She refused to sign. I told her that the doc would not treat her without the records. She suddenly stopped all her noise and told her husband "let's go, the won't give me anything but fluid and nausea medicine now." He got very threatening with me, loudly enough that the clerk summoned security and the staff came running. The patient was told she would be waiting in the lobby until there was a room available and that security would call the police if there were any disruptions. One of the staff members mentioned that the police were in the department. Upon hearing that, the couple suddenly decided to leave.

I figured they would be heading for the hospital across town, which caused me an evil grin. It is not well known, but the ER docs at that hospital also work in the hospital where they lived so I figured they would know her well.

Sometimes people do get what they deserve.

Why Triage is Important

When you come to the ER, the first step of the process is triage. A nurse will talk to you about the reason for your visit, obtain vital signs and gather some of your information such as medical history, medications and allergies. The word triage means 'to sort.' The triage process was developed on the battlefield to quickly sort large amounts of wounded soldiers into categories, basically dead or dying, urgent and can wait. The dead or dying were set aside so as not to waste resources better spent trying to save the salvageable. Fortunately in the ER we have enough resources to attempt to save everyone we are trained and prepared for that unthinkable day when a mass casualty incident may force us to return to battlefield triage.

Even though we aren't a battlefield, we triage people to ensure that the sickest get treated first. As I have tried to explain to the angry people in the lobby, the ER is not Burger King, it's not first come, first serve and get it your way. People in the process of having a heart attack, stroke or on the verge of not breathing need attention RIGHT NOW. Your chronic back pain, migraine, twisted ankle, cold sore etc. can wait a bit.


The triage nurse spends just minutes with the patient. In those few minutes she must determine how urgently the patient needs to be seen. This is made more difficult by the fact that patients often don't tell the nurse the whole story or they embellish or outright lie. Triage is an awesome responsibility. The nurse that does triage is away from the main ER and alone with the patient, they need to be an experience nurse who possess the assessment skills to look past the story and catch the subtle clues that something sinister may be going on.

For instance: A patient comes into triage, a man in his sixties with a complaint of being unable to move his bowels and abdominal pain. An inexperienced nurse would take down the information, and probably decided that the patient is constipated and send them to the lobby. An experienced nurse would notice that the patient is pale and sweaty and huffing and puffing a little bit. The nurse will ask him if he feels short of breath and after thinking a bit he'll answer that he does. She will get a wheelchair and take the man back to a resuscitation room even though the charge nurse may think she is nuts for rushing back a 'constipation.' The EKG will show the 'tombstones' of an acute MI. He goes emergently to the cath lab and is stented. He goes home two days later with minimal residual damage.

Now imagine the same situation with an inexperienced nurse. She takes the chief complaint at face value and sends him to the waiting room where he waits over three hours until his heart, irritated by lack of oxygen, suddenly goes into a fatal arrhythmia. Despite aggressive resuscitation, he dies.

Hospital administration thinks that a nurse is a nurse. It doesn't matter if they are experienced or a new grad, in fact a new grad is better because they are cheaper. Wonder which nurse they would want triaging them?

Imagine what would have happened.............

Grand Rounds

How wonderful, I just returned from the beach and I got to take another beach vacation today with Grand Rounds hosted by Eye on DNA. Thanks to Dr. Hsien-Hsien Lei for an outstanding edition of Grand Rounds.

Weak and dizzy all over = LONELY AND SAD!

Every ER staff member will tell you there is no chief complaint worse than 'weak and dizzy.' A very vague history and symptoms could mean any possible problem from cardiac, stroke, occluded carotids, labrinthitis, UTI, renal failure and so on and so on. The complaint usual comes from little old ladies (LOL) and means a long workup with no clear cut diagnosis ever identified. Weak and dizzy = 6 hour ER workup.

One hospital I worked out we had a patient who was turning out to be a problem child. A sweet, little grandmotherly soul, she was coming to our ER about 4 times a month with Weakness, dizzy, chest pain etc. All requiring lengthy workups. She had one of those PMD's that you can't get an appointment for 6 weeks and refuses to take any responsibility for her when she presented to the ER until every last diagnostic test known to man was completed and then, if admission was indicated, would try to palm it off on any consultant he could think of.

Sweet as she was, we were getting tired of the same old thing. She had significant co-morbidities and no doc ever felt comfortable not addressing her symptoms even though we all knew they were bogus. We suspected she was lonely, her husband had died in the previous year and all family lived far away, but despite repeated gentle talks about senior housing she was adamant about staying in her own home, alone.

About that time, the ER hired a full time social worker. The guy was a miracle worker, one day our sweet little frequent flier came in and he spent a couple of hours with her.

I never thought to much about it. The next time I saw her it had been eight months since her last visit and she was here with a significant UTI for which she refused admit! I remarked on the fact that we hadn't seen her for awhile and she confided that the social worker had talked her into a senior apartment in a lovely facility where she could eat in the dining hall and there were myriad trips and activities to fill her days along with friends and, best of all, a new boyfriend! She said she didn't know why she hadn't done that years ago.

We saw her rarely after that, always with a good medical reason. I'll tell you, a good social worker in the ER is worth their weight in diamonds!

Male Ills

Since my last post was on female problems, including PID which is often caused by Chlamydia, it only seems fair to talk about men suffering from similar complaints.

The fun starts in triage, some guys are shy about their problem and others are very forthright. One young man, in response to my usual question "what brings you to the ER today?) stated "I have stuff dripping out of my dick." I was rather startled and didn't reply for a beat or two. he must have taken that for disbelief because he asked, "Do you want to see?" No, I most certainly do not.

The ER course for this complaint consists of insertion of a tiny, flexible swab into the urethra to obtain a culture. Males (caution, sexist remarks follow) are babies. While definitely not a pleasant procedure, some of them carry on like their privates were being amputated without anesthesia. And I've noticed that the tougher and more 'gangsta' the patient, the more they whine. The entire procedure lasts less than 10 seconds. Then we give a shot of Rocephin IM followed by 2 grams of Zithromax.

I like to give the "wear a condom" talk after giving the shot, hoping that the burning buttock might cause them to listen. Probably not, I imagine most of them foolishly find it a reason to brag to their 'homies.'

Feminine Malady's

I'm back from vacation. Tanned,relaxed and five pounds heavier (drat!) I'm currently working my way through ten loads of sand caked clothes and sleeping bags and trying to catch up on all my Internet surfing, boy did you guys all do a lot of blogging while I was gone, it's gonna take more than one night to catch up on that! The first thing the ERkids did when they got home is go to friends' houses, guess three weeks camping with mom was their limit :)

I was reading some stuff and got to thinking about people who come to the ER and end up needing a pelvic exam. It happens fairly often, actually, even though I wouldn't have a pelvic in the ER if my female organs all suddenly prolapsed and I stepped on them - that is quite a picture ain't it- I'd take a lot of Motrin and wait until Monday. After all, I'm an intensely modest person and in addition to the procedure itself being unpleasant, the ER has exactly zero percent privacy - it'd be just my luck to be up in the stirrups, all the private areas waving in the breeze and have someone come blasting through the door, closed doors mean nothing in the ER. The horror.

Most females of child-bearing age with low abdominal pain need a pelvic to check for pelvic inflammatory disease or other pathology. A great deal of the ones that come to the ER are somewhat hygienically challenged, you get the picture. Add to that a small, overheated ER exam room crammed with a nurse, the doctor, the patient and often their friend/significant other/mother and you can have a very unpleasant situation. I have assisted where the patient was so malodorous it was a wonder the doctor didn't gag.

A heartbreaking situation is when a woman is having a miscarriage. Usually only weeks along, there is nothing we can do to stop natures process and in the busy chaotic ER, rarely have the time to spend with the woman that we need to. Nothing is worse than knowing you have failed to meet the psychological and emotional needs of your patient.

A satisfying situation is when a patient has a labial abscess, imagine the agony suffered with an abscess in such a tender area, often exacerbated because the patient hasn't come in right away because they were embarrassed. A simple I & D almost immediately improves their pain and they are well on the way to recovery.

Unexpected deliveries, I've written about that before, ER nurses don't like childbirth.

Often the problem is an infection, women with raging PID often walk with a peculiar hunched over gait, dubbed the PID shuffle. Their lower abdomen so painful they walk that way attempting to avoid jarring any of their internal organs. Part of the exam involves the doctor feeling the woman's uterus and ovaries to see if anything is enlarged or painful. He also moves the cervix back and forth to see if there is cervical motion tenderness, another sign of PID. In the ER we don't really call it 'cervical motion tenderness' we say she has positive chandelier sign because when it is painful the woman really jumps, like 'swinging from the chandelier. I have seen women with such terrible infections that the amount of purulent vaginal drainage was appalling, I remember on patient who spent her time in the ER walking around with no underwear dripping on the exam room floor. Yuck, please don't take the Wood's lamp in that room!

Sometimes the whole thing could be avoided if the patient would just say that all they want is a pregnancy test. But they know we'll tell them no so they say they have 'abdominal pain' and a late period. Now we have to rule out ectopic pregnancy etc. so instead of buying an $8 home pregnancy test or going to Planned Parenthood, they come to the ER and get a big workup.

No story like this would be complete without a few strange pelvic stories so here you go:

A medicine intern and a brand-spanking new travel nurse going into do a pelvic on a working girl with PID symptoms only to find it was a male going through sex change, beautiful hormonally enhanced breasts, long curly hair and a penis. We all knew the patient but neither of them had been in the ER prior to that day, the patient was listed as female even though surgery was not completed.

A rather large lady with abnormal vaginal bleeding having a pelvic by a doctor that weighed about 95 pounds. Sometimes it is all about the visual.

A woman who wanted artificial insemination. Uh....first of ll, that is not an emergency and just where did you want us to get the semen? Wait, don't answer that.

A woman who said she was being punished by God for impure thoughts. She actually had the worst case of genital herpes I have ever seen. Must have been more than impure thoughts.

I could go on and on but the dryer just beeped so off I go to fold laundry.