What Really Happpens in the ER at Night

Thanks to Kim for this pictoral essay of a night shift in the ER.

Alcoholim

In a comment on my previous post about drunks Maria has a link to article about an apartment building in Seattle that the city built to house some of their chronic homeless inebriates. Of course there was the expected furor from the public because the residents are allowed to continue drinking. The public thinks "they should have to stop." Get a clue people, they aren't going to stop, they can't stop. On the street they drive up crime rates, drive down property values and cost you billions of dollars in taxes every year, sure I think they should just stop drinking too but obviously that isn't going to happen so how about an alternative to multiple ER visits and increased jail costs dragging them to the drunk tank.

Two things about the article though, first it said that their had been 120 ambulance visits there and this was in 2006 so obviously they aren't doing enough to cut down on needless ER visits, how about hiring and training some care attendants of some sort to monitor those that have drank until they passed out or soiled and vomited themselves? Even if you had to pay nursing salaries and benefits it would be far cheaper than ER visits.

Secondly, I was saddened that the article pointed out that a great number of these people are veterans. What a sad indictment of our society that we will send you off to war to fight for our freedom but when you comeback with mental problems from the stress and horror - well too bad, you're on your own.

Drunks

Today I had a drunk who was brought in by ambulance for the second time in 14 hours with a complaint of altered level of consciousness, duh....a BAC over .3 will do that to ya', you don't need a doctor to tell you that one. On the second visit he was found walking around with his broken IV tubing trailing along behind him dripping blood all over the ER. When asked why he bit his IV tubing in half he looked at it and said "Did I do that?" Steve Urkel lives.

Seriously though, these people take up a huge amount of medical resources being paid for by your tax dollars. Since they can not appropriately take care of themselves they should be institutionalized which would be much cheaper for the taxpayers. And don't give me any crap about how we would be infringing upon their precious rights to drink themselves into a stupor every day and pass out in puddles of puke, shit and piss in public places so that someone has to call 911 to get them the heck out of there. That takes an ambulance out of service so that when someone's little old mom is having a big ole MI there is no ambulance to take her to the hospital. It takes up a hospital room so that when you are sitting in the waiting room dying from that kidney stone you have to just suck it up. It takes up BILLIONS OF DOLLARS of medical resources every year in my state alone. Sorry, I don't want to hear about their 'rights.' If you have such a bad substance abuse problem then you need to be taken care of for society's good.

"hey ERnursey, the patient in room 23 needs a warm blanket" I was informed by the doctor who had just left the room, walk past the blanket warmer, the nurses station, one of the ER techs to find me in a room on the other side of the ER where I was starting an IV on a screaming, squirming infant.

I just looked up at him and said "you are joking, right?" He didn't get it.

After I finished with the IV I hunted him down. "you know, you walked past the blanket warmer and expended ten times more energy to hunt me down then if you had just gotten the patient the blanket to begin with. It is not beneath you to do that." He just looked at me blankly. "never mind."

I shouldn't complain, I worked with a doc once that would come out and write an order 'give patient warm blanket.'

Seriously though, even though some jobs are more clearly nursing or physician related, patient comfort is everyone's job so when a patient asks for a blanket or urinal - hand them one for crying out loud!

I think it should be mandatory for all nurses in management, utilization review and QRM to work one shift on the floor. After all, if they are going to spend their time making up ever more burdensome paperwork for nursing and medical staff to use they should be forced to use it on a regular basis. I'll bet that if they did the mountain of paperwork would start to diminish noticeably.

New this week is a check sheet to check off that you have done all the paperwork. A piece of paper to prove that there is enough paper. Can you believe it?

Odd things

"My pain is a ten, it's really, realllllyyyyy baaaaad, zzzzzzzz, snort, it's the worstzzzzzzzzzzz" COME ON PEOPLE, if it is really bad you can't nod off while talking to someone, I've been there.

Seen recently on a local off ramp is a man holding a sign 'Need money for pot.' I almost gave him a buck because I was so impressed he wasn't trying to scam me. I pass the same spot every day and sometimes will see the same pan-handler two or three times a week for months - "hey dude, you've been at this for quite awhile, haven't you got enough gas money to get home yet?"

At the local supermarket I spot one of our regulars asleep in the landscaping, I inwardly groan and think that he'll beat me to work. Sure enough, a concerned citizen calls 911 fearing that there is a dead body and EMS duly delivers him to the ER for the 5th time this week.

Terrified parents bring their toddler in for 'vomiting blood' in triage the child vomits a remarkable amount of day-glo red vomit. "look she's doing it again!" ummm, that is most definitely not blood, has she been eating everything red? Little brother pipes up "she drank my red koolaid!" Ahhh, another life saved. We all laugh and the parents are greatly relieved.

Business as Usual?

Don't go to these hospitals until the strike is over, I cannot over-stress the importance quality, skilled nursing care has in good outcomes. Part of quality is adequate orientation to the hospital, a one day orientation just doesn't cut it. Yes, travelers do it all the time but they also have skilled staff there as a resource. Would you want your loved one crashing and all the nursing staff have less than 2 days experience in the hospital? Hell no. Seconds can make a difference in a critical situation and if the nurses don't know how to operate the equipment or find a crucial piece of equipment that can mean life or death. These hospitals should be sanctioned by DHS and JCAHO for continuing all but emergency services under strike conditions, I hope that the people in these communities will take their business elsewhere.

Grand Rounds

Oh heck, I forgot to submit to Grand Rounds this week. Check out this weeks edition at Pallimed.

How to Act out in public

OK, I shouldn't have to tell you this but here goes....if you are an employee in my hospital and you come to the ER I will do all I can to expedite things as a professional courtesy. I cannot whisk you immediately into a room if there were other sicker people waiting first but I will do my very best for you. Do not come to the ER in your place of employment and act like an asshole. Don't make unreasonable demands, if you are sitting in a packed waiting room and there is a pale, sweaty puking person in a chair across the room don't throw a fit when I bring them back to a room first. Do not call the nursing supervisor and have her call me five times to ask me why I'm not bringing you back to a room, I will bring you back to a room as soon as I can. Do not sneak back and follow me around the ER asking me when I will bring you back and for damn sure don't interrupt me when I am in a room with another patient. As an employee of the hospital I would expect you to be a grown-up professional person who knows how to act when out in public.

The Nurse is always to blame

I was reading this post by Kim at Emergiblog and it really got my dander up. The hospital administration comes up with a stupid ass rule, the nurse is supposed to document exactly what medication and dose the patient says they are taking even if they know it is wrong and then when the doctor orders it incorrectly without verifying that the information is correct it is the nurses fault that it got ordered wrong.

Excuse me? I don't think so doctor, you are a professional and as such are responsible for your own practice. I am not your babysitter. If you read the reconciliation sheet and it says Xanax 25mg you shouldn't just check off yes and move on. Of course the hospital administration is wrong in expecting the nurses to write down information that they know is erroneous but each of us is ultimately responsible for making sure our own practice is safe and without error.

I worked at a hospital years ago that had gotten into trouble on the JCAHO survey because the doctors were not signing their telephone orders within 24 hours. So who got in trouble? The doctors who knew darn good and well that this was a requirement? No, of course not, it was the nursing staff. Apparently we were supposed to be chasing them up and down the halls with all their charts pointing out each and every order for their convenience and if they didn't get signed in 24 hours the nurse that had the patients got written up. Being the supreme rabble rouser that I am, my response to this was to refuse to take orders over the telephone except for emergency, which was the policy anyway. Imagine how that went....."hello doctor, your patients blood sugar is 351 and the order reads to call you for over 350. No I am sorry you will have to come in from home and write that order because my hospital policy states I cannot take routine orders over the phone." Then when I got into trouble for that I had to ask the Director of Nursing if she was asking me to go against hospital policy.

Everyone of us is aware of the requirements of our job. No one has to follow me around and have me sign my med orders or point out where to fill in my check sheets. If I don't comply I get disciplined, plain and simple. That needs to be an expectation of medical staff also, yes sometimes the rules are ridiculous and cause us extra work and yes we don't like them but we are all grown ups and responsible for ourselves so grow up and don't try to blame your mistakes on someone else and don't expect me to follow you around and make me do your job.

And if I didn't already know it, I would suspect Kim works in California, I've worked in a lot of states and this one is the worst for making up ridiculous rules and regulations and taking ridiculous rules and regulations and making them even more cumbersome than they already are.

Sorry for the light blogging this week, I have been in full vacation mode! Here's a little story about something the ER son was involved in.

I'll be back at work tomorrow and full of new fuel for the blog!

Boarding Patients in the ER

Boarding patients in the ER is a problem, a big problem. Anyone in the ER knows it. You cannot stop the flow of patients into the ER but all the roads out of it are blocked for one reason or another. It is going to have to come down to some sort of legislation that admitted patients MAY NOT stay in the ER, ever. It is not safe for the patients, it is not safe for the ER staff and it is definitely detrimental to the sick and dying patients that need urgent treatment waiting for an open bed. Hospitals must be held accountable to get the admitted patients out of the ER. They must quit performing elective surgeries when the hospital is over capacity even though they are big money makers. It has to stop being about the pocketbook and start being about what is best for the patients. They must either bring in contract labor for times of high census or the administrators need to put on their nursing shoes and get out on the floors. The ER needs to become as much of a priority as the cath lab or surgery even though the reimbursement for ER patients is less. Administrators need to spend less time in useless meetings and come up with some real solutions NOW!

Grand Rounds

Grand Rounds this week at NY Emergency Medicine, check it out!

Do you know what a nurse knows?

Do you know what SIADH is and what drugs and conditions cause it and what the treatments are? Do you know what Diabetes Insipidus is and how to treat it? Do you know the different signs and symptoms associated with a right sided MI vs a lateral wall MI and the appropriate treatments? Do you know the signs and symptoms of a sub-arachnoid hemorrhage and the appropriate treatment? Do you know how to run a code or titrate 20 different vasoactive drips? Can you manage a vent, do you know what the alarms mean and how to find out what is wrong with the patient and how to fix it? Do you know how to make a CPS report? An APS report. Do you know the treatment for malignant hyperthermia? Do you know how to do post-code hypothermic therapy? Do you know the signs and symptoms of pneumonia and the appropriate antibiotic therapy? Do you know how to treat a patient in septic shock? Can you assist a Dr. in putting in a Swan-Ganz catheter, arterial line, Endotracheal tube, transvenous pacemaker, ICP monitor and can you tell the difference in the waveforms and what is normal and not? Do you know the drugs and dosages to treat pulmonary edema? Do you know how to care for a patient on a VAD or an IABP? Do you know the generic and trade names of thousands of drugs, the appropriate dosages and the adverse reactions associated with them? Do you know what tetralogy of Fallot is or how to care for an infant with transposition of the great vessels? Do you know the drugs that a transplant patient takes? Do you know what graft vs host disease is and how it is treated. Do you know the signs and symptoms of transplant rejection, blast crisis. Do you know what to look for after a patient has chemo? Do you know how to manage CVVH? Dialysis? These are just a few things that nurses do every day. This is why you need an experienced, trained, skilled nurse at your bedside.

Strike!

If you are considering being a strikebreaker take a minute and think again. As a nurse do you like being so over-worked that you cannot provide good patient care? Do you like being so rushed for time that you have to scrimp on your charting or sacrifice time that could be spent on patient teaching so you can get all the paper work done. Do you like being treated like a criminal when you incur a half hour to complete your charting. Do you like the CEO getting a $300,000 dollar raise while they cut your medical insurance benefits? Are you satisfied working in an environment where the medical staff are allowed to abuse you? How about having to use all your vacation hours up when the census is low and being worked half to death when there are sick calls. Do you like mandatory overtime? Do you like having to work a bunch of overtime to pay your bills? Do you like it when a new hire makes the same amount of money you do after working there ten years. Do you like it when a less qualified staff member gets the promotion because the manager likes her better? Do you like not having any input into your own nursing practice?

If you think that nurses strike over money you are dead wrong. Patient care issues are always at the heart of any strike and the decision to strike is heartbreaking to a nurse. It is the very last ditch effort. If nurses are striking then we need to band together and support them, they are trying to make it better for all of us.

Nurses are professionals, we deserve to have control over our practice. We deserve to have the time to provide safe, quality patient care. Our hours should not always be the first to be cut to save the hospital a few dollars.

WE WILL NEVER GET ANYWHERE AS A PROFESSION IF WE CAN'T STAND TOGETHER.

A Doctor Blogging from Iraq

Very powerful stuff can be found here. For those of us who forget sometimes that there is a war going on, and the whole world isn't like it is here.

The Publics Perception of a Nurse

I used to come home from the trauma center emotionally and physically exhausted after caring for multiple codes and critical patients, doing the fast paced nursing dance that kept people alive or helped them die with some dignity and relatively pain free. My husbands attitude when I complained about how bad a day I'd had would be something along the lines of "how hard could it be? You are only a nurse." Like he thought I spent the entire day fluffing pillows and patting fevered brows. Need I mention that that attitude, among a host of other things contributed to the fact that he is no longer my husband.

Lets talk about an ICU nurse. The doctors round once or twice a day for 10 minutes or so. The rest of the time it is a nurse at your bedside noticing the subtle changes that may indicate a problem and calling the doctor who, based on the nurses report, will give her orders over the phone without seeing the patient. Let's say the blood pressure is starting to drop and the fever is up. She'll call the doctor and he will order fluid boluses and blood, urine and sputum cultures. Then after that is all done she will call back because the pressure is still low and perhaps get an order for a potent vasopressor given as an IV drip. Now she does VS every five minutes or more while she titrates the medicine until the blood pressure stabilizes.

In the ER the docs are often managing 10 or more patients at one time, they see the patients when they come in and give orders and rely on the nurse to update them. I often will be titrating pain med on one person, treating a shock patient in another room, prepping a heart attack victim to go to the cath lab in another room. All requiring frequent vital signs and assessments. The goal is to know when a problem is developing from subtle signs and not let the patient get into trouble.

And still what do we see on TV? Five doctors in a room during a code and not a nurse in sight. Nurses playing the dumb blonde roll, nurses in low cut tight clothing and whole hospitals where the nurses either don't work there or are just shadowy figures pushing carts and pouring water in the background. Hollywood, get a clue!

And you nurses out there, toot your own horns, please don't say " Oh I'm just a nurse." when someone asks what you do. Educate the public about the very important work that we do because the media sure won't.

When a doctor assaults a nurse

I am fortunate to work with a great group of doctors, they are smart, funny, caring toward the patients and families and treat the rest of the staff, from nurse to clerk, like a valued and respected member of the team. I haven't always been so fortunate, one of my first jobs was in a small hospital where the nurses were treated like dirt by administration. Seeing that we had no respect or value by our employers some of the physicians felt free to mistreat us also. One was notorious for his especially foul and abusive behavior. When you would call about a patient he would belittle you, yell and swear at you and slam down the phone, that is on the rare occasion he deigned to return your page. When I first started working there I paged him to report a patient with a very high blood sugar, his office staff called back and tried to give me an order and was surprised when I wouldn't take it from her. Apparently that was the way 'it was always done.' Well not from me, I can only take an order direct from the physician so have him call me back. That kind of set the tone for our whole relationship.

He was the doctor I was talking about in the post about the ridiculous codes on people that were long past dead.

One day a man was brought in full arrest, he decided to put in a transvenous pacer. He was having a lot of trouble getting in the introducer so things were getting a little tense. He finally got it in and i had handed him the pacer wire, he started inserting it but it wouldn't thread, he kept pulling it back and trying again but it just wouldn't go. I asked him if he wanted me to open another wire as the one he had was kinked. He looked at me, pulled out the wire and threw it at me! The other people in the room just froze, no one knew what to do or say. It was a small hospital and the next hospital was an hour away, there wasn't many jobs and we didn't have a union. We knew administration would support him. I didn't much care, I was furious. After the code was called I confronted him. I should have called the police for assault with a deadly weapon. As suspected, I got no support from hospital administration, I didn't stay at that hospital for very long.

That was almost twenty years ago. I hope things have changed, I don't know what do you think? I'd be interested in hearing your stories.

Another type of entitlement

you read a lot in blogs etc. about the sense of entitlement we see in a good portion of the poor, welfare dependent, 'disabled', medicaid population. It has always fascinated me that people who contribute nothing to society feel that society needs to drop everything and be at their beck and call. How do people get that way? were you raised that way? I sure wasn't. I was brought up in a family where you were expected to pull your own weight. I had a full-time job at 15, they weren't too particular about child labor laws then. I have worked full-time plus since then except for maternity leaves. We were expected to pitch in at home, we all had chores we did every day and if we didn't get them done......well let's just say we got them done because we respected our parents and we knew there would be consequences. And they never laid a hand on us. Where did that kind of society go?

Well there is another type of person with a massive sense of entitlement, they are usually well-to-do with a white collar type of job. They think their wealth entitles them to special treatment and they are not nice about getting it. I was assaulted once by a family member who grabbed me by my arms and shoved me out of the room because the doctor hadn't met them when they arrived in the room after being force to wait with the riff raff in the lobby. They didn't like being told that the doctor was a little busy in a code at the moment. Then there are the ones who like to name drop, like they are friends with the CEO. Who cares, call him at home and see if he will come in and wipe you because I will not when you are perfectly able to do it yourself. Or "my husband is a cardiologist" well good for you, I hope he is nicer than the ones here, you still have to wait your turn.

The ER is the great equalizer. Everyone will be seen according to the severity of their illness. If the crackhead is coding he gets to go first, I don't care if you are the president of the university. If the heroin OD isn't breathing Mrs. Doctors wife, you are going to have to wait a bit. Please don't try to impress me with your credentials.

Eat, sleep, work, repeat.
Eat, sleep, work, repeat.

Vacation in three days yippee! But for now......SLEEP.

Send an Airman a care package

Please visit this site and send a service man a care package, this is for airmen but they have lengths for other branches. Remember that the holidays are approaching and our servicemen and women are far from their homes and loved ones. Take the time to show how much you appreciated their efforts on your behalf. A good sized flat-rate box only costs $7.95 to send. Things that my son says are greatly appreciated are DVD's, toiletries, books, magazines, local papers and letters from home. My younger child is having his class write letters to his brother and since his birthday is approaching his grandmother is having her friends at the senior center all do birthday cards for him.

Thanks EMS junkie for the link.

Endless Piles of Bureaucratic Bullshit

I have blogged ad nauseum about how I feel about JCAHO and the endless piles of paperwork their self-perpetuating bureaucratic regulations have spawned. Sigh.

But when I am feeling sorry for myself I can just always go and read this post on Police Inspector Blog and realize I don't have it so bad after all.

Sadly, this does not come as any surprise to us that work in the ER. I've been told that Vicodin sell for $10 a pill on the street here, that's a quick $200 bucks you can make on a two hour ER visit for say a sprained ankle, especially when you have medicaid and aren't paying a dime for your visit. Fentanyl patches are becoming readily available around here as we have seen an upsurge in young people who are unconscious from the powerful narcotic. That's a dangerous game.

Another fun party game is the pharm bowl, grab handfuls of pills out of mom and dads and grannies medicine chest and throw them in a bowl at a party and take unknown pills for fun. We've seen deaths and very near deaths from teens who have taken beta blockers and grannies anti-diabetic meds. Bet that wasn't all that fun to wake up in an ICU on a ventilator with tubes coming out of every orifice.

What is so terrible about life that such a large portion of our society wants to spend every day drugged to the gills? And these same people are out there driving on the road with you and me, nice huh? Pretty soon it won't be too hard for another country to come and take us over, we'll all be to stoned to care.

Update as requested

A couple of you have asked for an update on my son. He is doing good. He is aircrew on a big plane that flies over conflict at 35,000 feet and basically directs air warfare. They also do ground surveillance, in peace time one of their duties is anti-drug trafficking surveillance down in South America, before he was deployed he has been to Ecuador a couple of times. I feel a little better about him being over there because I know he is not on the ground where IED's are always a danger. He has been really busy flying which he likes but some of the flights are 20 hours long (I don't know where they are going and don't really want to think about it much.) so he is really tired. They fly all night and get back in the AM and get the rest of that day off.

I have sent him a few care packages, the thing he likes best are movies so I have been hitting up all the stores for their cheap movies and also Blockbuster's used movies, he has become quite popular for his movie selection.

He shares an 8 foot square room with three other men but it has air conditioning so that is good. He says the base is OK, it has a movie theater and even some fast food. They have not been allowed off base as it is Ramadan over there and after that is over they are only allowed off once a month. I don't know exactly where he is but I think it may be around Dubai, which tolerates Americans. I'd be just as happy if they never got to go off base at all.

The picture is a flight suit, which is what he wears. He says it is like a pair of comfy pajama's. Air Crew are also popular with the girls, like he needs any help in that area!

Thanks everyone for caring and all the support.


SUPPORT OUR TROOPS!

Um Doc? I think the patient is f&%#ing dead already.

When I was first a little baby ER nurse I worked in a little bitty rural hospital out in the butt-crack of nowhere. It had five beds and I was there alone with a PA. All the EMS were volunteer so if there was an ambulance call they had to leave their job (often in a barn somewhere) drive to the ambulance barn, get in the ambulance and go to the scene. Since we were in a very rural setting, the scene could be quite a ways away. When there was a code it could be 45 minutes or more before they got the patient to us and by then they were quite dead but that didn't stop us from coding them more, it was ridiculous.

When we knew there was a code coming in we'd call the doctor on call. One of those doctors was infamous for running the longest codes in the history of the universe. He'd put in a transvenous pacer and the whole bit on these poor bodies that had been down for and hour, half of that with no CPR. We hated it when he was on call. And since there were only three Internal med docs affiliated with the hospital, he could do no wrong in administrations eyes. It was really frustrating and back then there really wasn't much recourse if you wanted to hang on to your job. With the next hospital an hour away, I really wanted to hang on to my job, even though I HATED it.

One day we got a woman in that had been working near the river with her farmer husband. Something had happened and she lost her footing and went into the water, she didn't swim and neither did her husband. He had to hop on the tractor and drive to the closest phone then it took rescue awhile to get out there and even longer to find her, by then she was good and dead. EMS there was not allowed to call it in the field unless the body was decapitated or in full rigor so they started CPR and brought her to us. And of course DR. Lunatic showed up, had to put in a transvenous pacer and the whole nine yards. The code went on so long that in between rounds of epi the other nurse and I were cleaning up the room, emptying the trash and going out to check on the other patients. He didn't get the message. Hey doc are we trying for a resurrection here? Eventually the code was called but I decided I had enough and took a job at the other hospital even though it meant a long commute in the snow, believe me it was worth it.

Change of Shift

Girlvet is hosting Change of Shift this week, please stop by and check it out. And while you are there be sure to leave a comment thanking her on the time she spent putting out this weeks edition.

Grand Rounds

Don't forget to check out Grand Rounds over at Musings of a Distractible Mind. As if it isn't difficult enough to host a blog carnival, this weeks edition is don't in Doctor Seuss prose. Great job!

The Farm is a Dangerous Place

Farm accidents are plentiful, and one of the worst things is the PTO (power take-off) drive on the back of the tractor, it spins round and round and powers the equipment that is attached to the tractor, for instance the mower, tiller, baler, etc. New tractors have safety shields but in the majority of the farmers now-days are barely subsisting and can't afford a new tractor which can cost as much as a home.

Farmers wife with long hair gets to close to the PTO which grabs her hair and in less than a second, wraps the hair around the shaft, almost completely scalping the woman.

Farmer is attaching equipment to the PTO and gets too close, his coat sleeve gets caught and he suffers a traumatic amputation of his forearm.

Farmer is up in the hayloft of the barn chopping newspaper for bedding using a sileage chopper, his coat gets caught and he gets pulled into the chopper. His wife finds a horrific sight when she goes to look for him.

Farmer out plowing alone in a field loses control on a hill and rolls tractor over on its side, pinning him underneath the wheel. It is several hours before someone comes to look for him, his pelvis is broken into 18 pieces.

Our policy is if we are going to give narcotics and discharge you, you must have a driver at your bedside BEFORE you get your meds. Why? Well how about a couple of examples:

1. Disabled cop in for back pain tells me his ride is waiting for him in the car. Riiiighhhhttt. Ok sir, do you really expect me to believe that your driver is sitting outside in the car when it is 117 degrees out there? And you should know better being a former police officer than to try to lie to me so you can drive yourself home.

2. Lady that got Ativan for anxiety sneaks out the back door and crashes into another car in the parking lot.

3. A guy that got Dilaudid for migraine states that his brother, sitting in the room, will drive him home. Before he leaves another visitor here with a different patient informs us that the patient tried to pay him $20 to say he was the driver. Surprise, when confronted, the 'brother' fesses up.

I could go on and on but let me finish by saying this:

"ATTENTION all patients who will be receiving narcotics and then be discharged. I am sorry I am inconveniencing you by coming up with silly rules about needing to have a driver. But if you think I am going to let you leave and drive, thereby risking the lives of my kids, my family, the families of all my friends and coworkers as well as every other innocent person on the road because you have some sense of entitlement that you should not have to follow the rules you are nuts. So when you whine to me about being sent back out to the lobby to find a ride and free up a room I only have one thing to say......TOUGH SHIT."